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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600753
Report Date: 07/18/2024
Date Signed: 07/18/2024 12:58:34 PM

Document Has Been Signed on 07/18/2024 12:58 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/
DIRECTOR:		PIGGEE, KEVINFACILITY TYPE:
735
ADDRESS:2426 MARCELLATELEPHONE:
(626) 913-9994
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Kevin Piggee, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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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 Thamia Giles. The facility serves developmentally disabled residents under age 59. The facility is licensed as a level 4I Adult Residential Facility (ARF) vendored by San Gabriel/Pomona Regional Center. The 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 following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility staff are using appropriate hand hygiene cleaning and disinfecting the home. An Infection Control Plan was reviewed.

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. The facility has one (1) fully charged fire extinguisher. Hot water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for four (4) ambulatory only 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 7/1/2025.



Staffing: A total of eight (8) 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, and health screening. Staff (S5 & S6) have expired Pro-Act training.

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

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 07/18/2024
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Resident Rights/Information: Resident Personal Rights poster is posted in the dining area. 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: Four (4) 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 2/21/2024.

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

Per Title 22 one deficiency was cited.



Exit interview was 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: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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Document Has Been Signed on 07/18/2024 12:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/18/2024 at 12:53 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: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 (S5 & S6) has expired Pro-Act training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Administrator agreed to submit proof that S5 & S6 have current Pro-Act training.
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: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


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