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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600753
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:00:27 PM

Document Has Been Signed on 07/13/2023 01:00 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 IIIFACILITY NUMBER:
198600753
ADMINISTRATOR:PIGGEE, KEVINFACILITY TYPE:
735
ADDRESS:2426 MARCELLATELEPHONE:
(626) 913-9994
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Kevin Piggee, AdministratorTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to staff Janet Fagbohun. Administrator Kevin Piggee arrived later. There are four (4) ambulatory developmentally disabled adults ages 18-59. The facility is licensed as a level 4i home vendored by San Gabriel/Pomona Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility encourages hand washing and self symptom check of staff and visitors. COVID-19 off site isolation plan is in place.The facility has an Infection Control Plan and COVID-19 mitigation plan.


Physical Plant/Environment Safety:
  • Facility is a single story home licensed for 4 ambulatory residents. It is located in a residential area consisting of 3 client bedrooms, dining room, kitchen, living room, family room, 2 bathrooms, backyard with shaded patio furniture, and detached 2-car garage. The facility has a fire pull-alarm.

  • 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 are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.

  • Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
See next page
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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 III
FACILITY NUMBER: 198600753
VISIT DATE: 07/13/2023
NARRATIVE
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Operational Requirements:
  • The Program Design is current.
  • Fire clearance has been approved for four (4) ambulatory residents.
  • Care and supervision to meet the clients needs was observed. No special equipment and supplies are used by clients.
  • Surety bond was reviewed and is current.

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

Personnel Records/Staff Training:
  • Administrator certificate expires 7/9/2024.
  • Four (4) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, certifications, and 1st Aid/CPR training. Staff (S1-S3) do not have current Pro-Act training certification. Citation was issued.

Client Rights/Information:
  • Physician orders, and personal rights were reviewed in client files.

Client Records/Incident Reports:
  • Four (4) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, IPP reports, personal rights, medical consent, nutritional assessments, and medication administration records. Personal & Incidental (P & I) monies/records were reviewed.

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.
  • There are no physician orders for modified diets.

See next page.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
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 III
FACILITY NUMBER: 198600753
VISIT DATE: 07/13/2023
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Health Related Services:
  • Clients are assisted with self administration of prescription and non-prescription medications.
  • Two (2) centrally stored resident medication 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 clients have a Needs and Services Plan and COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. However, form LIC 610D is not current. Licensee is required to have an emergency disaster plan/Disaster and Mass Casualty Plan. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. Citation was issued.
  • An emergency drill was conducted on 5/2/2023.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care.

Per Title 22, California Code of Regulations, deficiencies were cited.


Exit interview conducted with Administrator Kevin Piggee. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2023 01:00 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/13/2023 at 12:30 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 III
FACILITY NUMBER: 198600753

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

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 thatAdministrator does not have the current LIC 610D "Emergency and Disaster Plan"; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator agreed to submit a copy of LIC 610D.
Type B
Section Cited
CCR
85165(h)(1)
Emergency Intervention Staff Training
(h) The licensee shall maintain a written record of the staff training. (1) Documentation of the training received by each staff member shall be maintained in the personnel records, pursuant to Section 80066, and include:

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 staff (S1- S3) do not have current Pro-Act certification training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2023
Plan of Correction
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Administrator agreed to submit proof of Pro-Act training for staff (S1- S3).
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: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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