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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600754
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:34:59 PM

Document Has Been Signed on 09/05/2023 04:34 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 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:
09/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Ketih Givan, DSPTIME COMPLETED:
04:40 PM
NARRATIVE
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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 Keith Morgan. Administrator Jason Piggee was explained the purpose of the visit telephonically. 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. Twelve (12) Adult CARE tool domains were observed and reviewed.

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. The facility has an Infection Control Plan and COVID-19 mitigation plan.


Physical Plant/Environment Safety:
  • 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 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. Cleaning supplies were observed unlocked in bedroom # 3. Staff immediately removed them and locked them. Citation was issued.

  • Bedroom #2's wall has a hole and walls are dirty.

  • 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: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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 IV
FACILITY NUMBER: 198600754
VISIT DATE: 09/05/2023
NARRATIVE
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Operational Requirements:
  • Fire clearance is approved for four (4) ambulatory residents only.
  • Care and supervision to meet the clients needs was observed. Special equipment and supplies are not used by clients.
  • Surety bond is in place.

Staffing:
  • A total of seven (7) staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expires 12/1/2024.
  • Four (4) staff files were reviewed. Personnel records are incomplete. Criminal background clearance and Pro Act training for staff (S2- S4) was on file. Staff (S3 & S4) files are missing required documentation/training. Administrator file is not in premises. Citation was issued.

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

Client Records/Incident Reports:
  • Four (4) resident 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: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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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 IV
FACILITY NUMBER: 198600754
VISIT DATE: 09/05/2023
NARRATIVE
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Health Related Services:
  • Residents are assisted with self administration of prescription and non-prescription medications.
  • Centrally stored resident medication records were reviewed. They 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 COVID-19 vaccination cards on file.
  • Staff training was on file.

Disaster Preparedness, and Emergency Intervention:
  • A current Emergency Disaster Plan LIC 610D containing emergency evacuation information was not provided. 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.
  • The last emergency drill was conducted on 2/10/2023. It is not within the last 6 months. Citation was issued.


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 staff Keith Givan. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/05/2023 04:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2023 at 03:55 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 IV
FACILITY NUMBER: 198600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 bedroom #2's wall has a hole and walls are dirty; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator shall submit picture proof of corrections.
Type B
Section Cited
CCR
80023(d)
Disaster and Mass Casualty Plan.
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 fire drill was conducted on 2/10/2023; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator agreed to submit a copy of a current Fire/Emergency drill.
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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2023 04:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2023 at 04:02 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 IV
FACILITY NUMBER: 198600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings and Grounds
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.
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 cleaning supplies were unlocked under bathroom sink in bedroom # 3; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2023
Plan of Correction
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Staff immediately removed the cleaning supplies and locked them in another location. ***Citation was 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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2023 04:34 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/05/2023 at 04:08 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 IV
FACILITY NUMBER: 198600754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel records
(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above in which staff records were incomplete and/or not available for LPA to review; which poses a potential health and safety risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Licensee shall ensure all personnel records are maintained on site and available for Licensing to review upon request. Submit a written statement of how the deficiency was corrected and proof that files at the facility are complete.
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 that the facility does not have the current LIC 610D Emergency and Disaster Plan; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Administrator shall submit a copy of the updated LIC 610D Emergency and Disaster Plan. Facility shall post the plan.
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: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


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