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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600752
Report Date: 11/16/2021
Date Signed: 11/17/2021 08:52:59 AM

Document Has Been Signed on 11/17/2021 08:52 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 IIFACILITY NUMBER:
198600752
ADMINISTRATOR:KEVIN PIGGEEFACILITY TYPE:
735
ADDRESS:2733 MELISSA STTELEPHONE:
(626) 810-4300
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Karla WilliamsTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with DSP staff Karla Williams and explained the purpose of the visit. There are six (6)) level 4G developmentally disabled clients ages 18-59. The facility is serviced by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood that is licensed for 4 ambulatory and 2 non-ambulatory clients. It consists of 3 bedrooms, 2 bathrooms, living room, family room, dining room, office room, laundry room, kitchen, outdoor covered patio, and attached garage. The last fire drill was conducted on 4/29/2021.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. An unlocked laundry detergent bottle was observed in the laundry room shelf. Staff immediately locked the detergent.
  • COVID-19 Infection Control signs were observed in the entrance, common areas, hallways, and bathrooms. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • One (1) room has been designated as a COVID-19 solation room if needed.
  • Three (3) centrally stored resident medication records were reviewed.
  • Staff was observed wearing a surgical mask.
  • Clients in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Staff and resident files were not reviewed during today's visit.
  • Based on record review observation the last disaster drill was conducted on 4/29/2021, and shall be conducted at least every 6 months; which is now past due.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with DSP Felicia Dioron. A copy of the report and appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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Document Has Been Signed on 11/17/2021 08:53 AM - It Cannot Be Edited


Created By: Noemi Galarza On 11/16/2021 at 03:16 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: CENTER FOR BEHAVIORAL CHANGE II
FACILITY NUMBER: 198600752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 in that at 2:34 pm a laundry detergent was observed on top of the laundry room shelf accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Staff immediately locked the laundry detergent observed in the laundry room.
***Deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/17/2021 08:53 AM - It Cannot Be Edited


Created By: Noemi Galarza On 11/16/2021 at 03:16 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: CENTER FOR BEHAVIORAL CHANGE II
FACILITY NUMBER: 198600752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)
Disaster & Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the last emergency/disaster drill was conducted on April 29, 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2021
Plan of Correction
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Administrator shall conduct a disaster drill and submit proof of correction by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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