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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600754
Report Date: 09/29/2022
Date Signed: 09/29/2022 11:50:20 AM

Document Has Been Signed on 09/29/2022 11:50 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 IVFACILITY NUMBER:
198600754
ADMINISTRATOR:PIGGEE, JASON A.FACILITY TYPE:
735
ADDRESS:2755 MIRANDA STREETTELEPHONE:
(626) 839-5115
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Norma Morgan, DSPTIME COMPLETED:
11:55 AM
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 staff Norma Morgan and explained the purpose of the visit. There are four (4) ambulatory level 4i developmentally disabled clients in the home. The facility is a single story home located in a residential neighborhood. It consists of 3 client bedrooms, 2 bathrooms, dining room/family room, kitchen, living room, outdoor patio, and detached garage. The last fire/emergency drill was conducted on 7/12/2022. Administrator certificate expires 12/1/2022.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. The facility is equipped with a fire pull alarm system. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • Each client room is designated as a COVID-19 isolation room if needed.
  • A posted Emergency Disaster Plan was not observed.
  • Four (4) centrally stored client medication records were reviewed. Medications are documented properly and given as prescribed.
  • Staff were observed wearing mask. Clients do not wear masks due to disability exemption.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C).
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • All staff have fingerprint clearances.
  • The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan.
Discarded gardening and grilling materials (sharp cleaning tools) were observed in the side yard. See 809D.
Exit interview was conducted with staff Norma Morgan A copy of the report and appeal rights will be emailed due to document printing problems.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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Document Has Been Signed on 09/29/2022 11:50 AM - It Cannot Be Edited


Created By: Noemi Galarza On 09/29/2022 at 11:10 AM
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 IV
FACILITY NUMBER: 198600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 the side yard area had discarded gardening and grilling materials (sharp cleaning tools) next to the house wall; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Licensee shall discard debris and/or store the items so that they are not accessible to clients or a tripping hazard.
Submit picture proof evidence that items were removed.
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: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


LIC809 (FAS) - (06/04)
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