198600752-8-30-2024-28-AS-NGAA-D8BRAE-20240820125101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600752
Report Date: 08/20/2024
Date Signed: 08/30/2024 02:43:18 PM

Document Has Been Signed on 08/30/2024 02:43 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CENTER FOR BEHAVIORAL CHANGE II		FACILITY NUMBER:	198600752
ADMINISTRATOR:	KEVIN PIGGEE		FACILITY TYPE:	735
ADDRESS:	2733 MELISSA ST		TELEPHONE:	(626) 810-4300
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	6	CENSUS: 5	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Olayinka King, Assistant Administrator		TIME COMPLETED:	12:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced annual inspection visit. The purpose of the visit was explained to DSP Lidia Small. Assistant Administrator Olayinka King arrived shortly after. The facility serves developmentally disabled residents under age 59. The facility is licensed as a level 4G Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The facility is a single story home located in a residential neighborhood consisting of 3 bedrooms, 2 bathrooms, living room, family room, dining room, office room, laundry room, kitchen, outdoor covered patio, and attached garage. The following 12 (CARE) tool domains were utilized during the inspection

Infection Control: The facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors were tested and are operational. A fire-pull alarm was observed. The facility has (2) fully charged fire extinguishers. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients. Hot water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit; readings were 129.7- 129.9 DF. Resident (R2's) mattress had a metal spring sticking out in the lower part of the mattress.

Operational Requirements: Fire clearance is approved for four (4) ambulatory and (2) non-ambulatory residents. Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients. Facility manages residents P & I monies. The Surety Bond expires 7/17/2025.

Staffing: A total of (9) staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Six (6) staff files were reviewed. Criminal background clearance, in-service training, 1st Aid/CPR training, CPI/ Pro-Act training and health screening.

Administrator certificate expired 7/9/2024. Mr. Piggee provided proof that recertification training was submitted on 6/25/2023 and is currently pending.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198600752
	VISIT DATE: 08/20/2024

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Resident Rights/Information: Resident Personal Rights poster is posted in the hallway. Internet access is available for residents. Physician's orders are on file. No residents require modified diets. HCBS Rights are posted.

Resident Records/Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, Behavior Reports, TB clearance, personal rights, medical consent, medication records, and P & I records. Files have been updated with HCBS Tenant/Landlord Rights and Responsibilities Agreement.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Medications records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions. 30-Day supply of medications were observed.

Incident Medical and Dental: All residents have a Needs and Services Plan and updated medical assessments.

Disaster Preparedness, and Emergency Intervention: LIC 610D form "Emergency Disaster Plan/Disaster and Mass Casualty Plan is current.

The last Fire/Emergency Drill was conducted on 7/17/2024.

Emergency Intervention: Facility uses Pro-Act and CPI de-escalation and crisis reduction techniques.

Per Title 22 two deficiencies were cited.

Exit interview was conducted with Assistant Administrator Olayinka King. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198600752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the hot water readings ranged between 129.7- 129.9 D, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	Administrator shall adjust the hot water temperature and submit a water temperature log that shows each shift today and tomorrow tested the hot water in all facility sinks.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 198600752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85088(c)(1)

Fixtures, Furniture, Equipment, and Supplies

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that resident (R2's) mattress had metal springs sticking out in the lower part of the mattress, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Assistant Administrator immediately removed R2's damaged mattress and placed another mattress on the bed during the visit. ***Citation was cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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