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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600751
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:57:53 AM

Document Has Been Signed on 08/23/2022 10:57 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: 5DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:S-1TIME COMPLETED:
11:00 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.

This home consists of (3) bedrooms, (2) bath, living room, family/t.v. room, kitchen, dinning area and attached garage.

The following were observed/inspected:
  • COVID-19 Infection Control Practices were observed at the entrance of this home and in all common rooms and hallways. Signs were posted throughout the facility.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Bathrooms had hand washing signs, liquid soap and paper towels.
  • Medications for (5) clients were reviewed for Client #1 through Client #5 (C-1 through C-5).
  • 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. Additional supply is stored inside the garage. Additional water supply was also observed.
  • Sufficient PPE supply observed. Additional supply is stored inside the garage.
  • Per S-1, (5) clients have both COVID-19 vaccines and booster.
  • Per S-1, COVID testing occurs every Tuesday.
  • Clients were socially distanced according to local public health guidelines.

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: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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