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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:17:46 PM

Document Has Been Signed on 04/28/2022 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR:MOHAMMED SHIRAZIFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
04/28/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mohammed Shirazi, Administrator TIME COMPLETED:
02:20 PM
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An Informal Meeting was held via Microsoft Teams with Monterey Park Adult and Senior Care Regional Office staff of the Community Care Licensing Division (CCLD). The purpose of the meeting is to discuss three (3) Age Exception requests, client population, and required regulations. The attendees present during the meeting were: CCLD Licensing Program Analyst (LPA) Noemi Galarza, People's Care Residential Services District Manager Christopher Trevilla, Administrator Mohammed Shirazi, and Eastern Los Angeles Regional Center Service Coordinator Gladis Oropeza.

DISCUSSION:

Required Residential Care Facility for the Elderly (RCFE) regulations that shall be adhered to upon approval of the Age Exception request. The following regulations shall be followed: 85068.4 (a-h), 80010 (a-b), 87303(e) 4-5,(h); 87411(c)(3)(a-f); 87415(a); 87458(a); 87459(a); 87456(a); 87463(b); 87464(f)(6); 87466. A copy of the regulations were provided to Licensee. Requirements will be in place until the entire client population at the facility falls below the age of 60.

People's Care staff acknowledged receipt and understanding of RCFE requirements discussed. Mr. Shirazi stated that he has an RCFE Administrator certificate, and RCFE regulation staff training has been put into place. District Manager Christopher Trevilla stated People's Care elderly clients visit their Primary Care Physician's every other month, and are also frequently evaluated by an RN consultant for any changes in condition. A case management visit will be conducted to review compliance once the Age Exception Requests have been approved.

Copies of the regulations were provided. Facility staff were informed that they will receive approval notification of the Age Exception Requests via mail.

Exit interview was conducted. A copy of the report was emailed to Mr. Shirazi.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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