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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 01/12/2023
Date Signed: 01/12/2023 04:16:26 PM

Document Has Been Signed on 01/12/2023 04:16 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
GREATER LA AC/SC, 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:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Joji Jonson, StaffTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA met with staff, Joji Jonson, and explained the purpose of the visit.
The facility is approved for four (4) developmentally disabled adults, ages 18 - 59, and one may be non-ambulatory. There are currently 4 clients residing at the home and receive services from the Eastern Los Angeles Regional Center.

LPA Chan toured the facility and observed the following:
* There are a total of 5 bedrooms (4 Client bedrooms and 1 bedroom for live-in staff), 2 bathrooms, living room, kitchen, office space, and a detached garage. There are no pool or bodies of water on the premises. There are no items obstructing the walkways. The facility has proper Coronavirus (COVID-19) signage at the main entrance and around the home. Hand washing signs are posted in each of the bathrooms and kitchen sink. Staff are continuing to screen all visitors and staff upon entry. Staff and clients' temperature are also taken daily and documented. Sufficient PPE supplies are stored at the facility. The smoke detectors and carbon monoxide detector are operable. Food supplies for 2 day perishable and a week of non-perishable were observed. Knives and sharps are stored and locked under the kitchen sink. Cleaning supplies are stored and locked above the washer and dryer. Medications are centrally stored and locked in the kitchen cabinet. LPA reviewed all 4 medications and staff are administering them as prescribed by the physician. Emergency contact information for clients are most current and emergency contact numbers are posted on the bulletin board. All staff on duty were wearing face masks. Staff are still following COVID-19 guidance and disinfecting all high touched surfaces every 2 hours.

No deficiencies were observed during the visit today. An exit interview was held and a copy of this report was provided to staff Jonson.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2023
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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