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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 10:23:15 AM

Document Has Been Signed on 03/12/2024 10:23 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:POCUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Victorina Tongco - CaregiverTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Plan of Correction (POC) visit to follow up on a citation that was issued on 2/13/24 during the facility's Annual Inspection. LPA met with Victorina Tongco who assisted with the visit.

On 2/13/2024 the facility was cited for:

80088(e)(3): 80088 Fixtures, Furniture, Equipment, and Supplies; (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.



During todays visit (3/12/24) LPA observed sink in client bathroom to be working and distributing hot water.

On today's POC Visit the Proof of Correction (POC) is cleared.


Exit interview conducted and a copy of this report was 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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