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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600751
Report Date: 10/11/2021
Date Signed: 10/12/2021 08:26:45 AM

Document Has Been Signed on 10/12/2021 08:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CENTER FOR BEHAVIORAL CHANGE IFACILITY NUMBER:
198600751
ADMINISTRATOR:JASON A PIGGEEFACILITY TYPE:
735
ADDRESS:604 E MCKINLEY AVETELEPHONE:
(909) 865-2354
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:S-1TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPAs met with S-1 and explained the purpose of the visit. There are (6) clients residing at this home. All clients receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this home, in all common rooms and hallways.
  • Three (3) client rooms were inspected.
  • Medications for (6) clients were reviewed for Client #1 through Client #6 (C-1 through C-6).
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. There are additional supplies stored inside the garage.
  • Sufficient PPE supply observed. There are additional supplies stored inside the garage. Hand sanitizer observed throughout the common areas of this facility.


There are no deficiencies noted.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-1
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
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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