198600754-8-22-2024-28-AS-NGAA-D8DR3E-20240822123949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600754
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:40:30 PM

Document Has Been Signed on 08/22/2024 12:40 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 IV		FACILITY NUMBER:	198600754
ADMINISTRATOR:	PIGGEE, JASON A.		FACILITY TYPE:	735
ADDRESS:	2755 MIRANDA STREET		TELEPHONE:	(626) 839-5115
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	4	CENSUS: 4	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Denise Brown, Assistant Administrator		TIME COMPLETED:	12:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Noemi Galarza made an unannounced Required - 1 year annual inspection visit. The purpose of the visit was explained to DSP Norma Morgan. Administrator Jason Piggee was explained the purpose of the visit telephonically. Assistant Administrator Denise Brown arrived shortly after. 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 single family home is located in a residential area consisting of 3 client bedrooms, 2 bathrooms, dining room/family room, kitchen, living room, backyard with outdoor patio, and detached garage. The facility has a fire pull-alarm. 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. 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 8/24/2025. The facility also has Liability Insurance.

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

Personnel Records/Staff Training: Five (5) staff files were reviewed. Criminal background clearance, in-service training, 1st Aid/CPR training, and health screening.

Administrator certificate expires 12/1/2024.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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 IV	FACILITY NUMBER: 198600754
	VISIT DATE: 08/22/2024

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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 in the common areas and in resident rooms.

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 reviewed.

Incident Medical and Dental: Files have Needs and Services Plan and updated medical assessments, with the exception of resident (R1). The resident moved in on 5/31/2024.

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

The last Fire/Emergency Drill was conducted on 2/29/2024, within 6 months of Title 22 requirement.

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

Per Title 22 one deficiency was cited.

Exit interview was conducted with Assistant Administrator Denise Brown. 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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/22/2024 12:40 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 IV	FACILITY NUMBER: 198600754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that R1 moved in on 5/31/24 and their file did not have a medical assessment, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a copy of R1's Physical Exam.

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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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