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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600640
Report Date: 02/24/2025
Date Signed: 02/24/2025 05:24:31 PM

Document Has Been Signed on 02/24/2025 05:24 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/
DIRECTOR:
JOHNSON, JUSTINFACILITY TYPE:
735
ADDRESS:1702 ROBIN LINDA LNTELEPHONE:
(626) 927-9177
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 4CENSUS: 4DATE:
02/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:11 PM
MET WITH:Justin Johnson, Adminitrator TIME VISIT/
INSPECTION COMPLETED:
05:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required unannounced annual inspection. LPA met with Caregiver/House Lead Jenniben “Jenny” Baltazar and explained the reason for the visit. Administrator Justin Johnson, arrived a short time later and assisted with the visit. The facility is licensed to serve 3 Ambulatory and 1 Non-Ambulatory Developmentally Disabled Adults ages 18-59. Facility currently has 4 Ambulatory clients serviced by Eastern Los Angeles Regional Center. Currently three (3) clients are over 60 years of age.
The facility is a single-story home located in a residential area in Rosemead, Ca. A tour of the facility includes living room, dining area, kitchen, 4 client bedrooms, 2 bathrooms, detached garage, staff office/laundry area, front yard and back yard.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the kitchen and client bathroom and were within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Eaves around the back of the home are in need of painting.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 01/31/2025.

(Continued on the LIC809-C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 ROSEMEAD
FACILITY NUMBER: 198600640
VISIT DATE: 02/24/2025
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(continued from 809)
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location within a locked closet in the staff office area. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, Current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Justin Johnson Certificate expires on 04/11/2026.
Client Rights-Information: Facility provides telephone landline for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained within the staff area in a locked closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files and C1 requires age exception as C1 is now over 60. C1,C2, and C3 need Physicians Report for the Elderly (RCFE) LIC602 as they are all over 60 years of age.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked kitchen cabinet and are in their original containers. LPA reviewed 4 client’s medications during todays visit with no issues.
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. Emergency Disaster Plan needs updating.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff at facility do maintain valid CPI certificates.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit are documented on the 809-D. Technical Advisory provided.

Exit interview was held and a copy of the report was given to Justin Johnson, Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/24/2025 05:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 02/24/2025 at 05:00 PM
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: 02/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The Eaves around the back of the home need painting which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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Administrator will paint the eaves around the back of the home and send proof to LPA by POC DATE.
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. C1, C2, C3 all need Residential Care Facilities for the Elderly (RCFE) assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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Administrator will obtained updated Residential Care Facilities for the Elderly (RCFE) LIC602 for C1, C2, and C3 and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2025


LIC809 (FAS) - (06/04)
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