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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 03/12/2024
Date Signed: 03/12/2024 10:22:30 AM

Document Has Been Signed on 03/12/2024 10:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAISER SPECIALIZED RESIDENTIAL ROSEMEADFACILITY NUMBER:
198600640
ADMINISTRATOR:JOHNSON, JUSTINFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Victorina Tongco - CaregiverTIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit, LPA met with Victorina Tongco who assisted with the visit. The purpose for this visit was explained and was originally for a Plan of Correction (POC) on a citation that was issued during the facilities Annual Inspection dated 2/13/24.

However, during the POC visit, LPA observed client bathroom sink hot water temperature to be 130.1 degrees F, which is outside of the required range of 105-120 degrees F, deficiency will be cited on 809D.

Exit interview conducted and a copy of this report and appeal rights were provided to Victorina Tongco.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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Document Has Been Signed on 03/12/2024 10:22 AM - It Cannot Be Edited


Created By: Tena Herrera On 03/12/2024 at 09:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL ROSEMEAD
FACILITY NUMBER: 198600640

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
CCR
80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
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**During visit maintenance staff lowered hot water temperatrue on the water heater**
Administrator/Licensee to ensure that the hot water temperatrure is within the required range of 105-120 degrees F.
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Based on observation, the licensee did not comply with the section cited above as hot water temperature in client bathroom measured at 130.1 degrees F during todays visit, which poses an immediate health, safety or personal rights risk to persons in care.
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 A log documenting the hot water temperature for the next 5 consecutive days (morning, day and night) to be submitted to LPA via email by 3/19/2024 (with each reading within required range). Log will have a beggining date of 3/13/24 and will end evening of 3/18/24.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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