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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600754
Report Date: 08/04/2025
Date Signed: 08/04/2025 01:22:42 PM

Document Has Been Signed on 08/04/2025 01:22 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/
DIRECTOR:		PIGGEE, JASON A.FACILITY TYPE:
735
ADDRESS:2755 MIRANDA STREETTELEPHONE:
(626) 839-5115
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
08/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Denise Hicks, Administrative AssistantTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to DSP Aloy Ohia. Administrative Assistant Denise Hicks arrived later. The facility is licensed as level 4I Adult Residential Facility (ARF) that serves developmentally disabled residents ages 59 and under vendored by San Gabriel/Pomona Regional Center.

The following were observed/inspected:



Infection Control: The Infection Control Plan includes Environmental cleaning and disinfection activities. Facility has sufficient Personal Protective Equipment/supplies.

Physical Plant/Environment Safety: The facility is a single story home 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. Smoke and carbon monoxide detectors were tested and are operational. The facility has one (1) fire extinguisher and a fire pull alarm. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has a 1st Aid Kit and Manual. Cleaning supplies, knives, and toxic substances are inaccessible to residents. Exit doors are free of any obstruction and there are no pools or large bodies of water.

Three holes were observed in C1's bedroom and 1 hole was observed in the living room wall.

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 or supplies are used by residents. The Surety Bond expires 8/24/2025.



Staffing: A total of 7 staff members provide care and supervision to the clients.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/04/2025
NARRATIVE
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Personnel Records/Staff Training: Administrator certificate expired 12/1/2024, pending recertification processing. Criminal background clearance and staff roster were reviewed. Administrator file was not available for review, and S3’s file was missing the personnel record. Continuation education training documents were not available for review and training logs on site have not been updated. Citations were issued.

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

Client Records/Incident Reports: Four (4) files were reviewed. Admission agreements, Physician's Report, medical/functional assessments, ISP's, TB clearance, IPP reports, personal rights, medical consent, dietician report, consultant logs, Personal & Incidental (P & I) monies/records, and Medication Administration Records were reviewed. P & I money ledgers were reviewed. Client (C1) had an annual physical, but no Physician's Report/Physical Exam form was completed by MD. A technical advisory was issued.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable, 7 day non-perishable food, and emergency supply of food and water. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. No residents require a modified diet.

Health Related Services: Residents are assisted with self administration of prescription and non-prescription medications. Centrally stored resident medication records were reviewed and are given according to Physician directions. 30-Day supply of medications were reviewed.

Incident Medical and Dental: Residents have updated consultant assessments, Physician Reports, and COVID-19 vaccination cards on file.

Disaster Preparedness, and Emergency Intervention: Emergency Disaster Plan was reviewed. The plan shall be reviewed annually, updated as necessary, and maintained on file at the facility. First Aid Kit and Manual were observed. The last emergency drill was conducted on 2/4/2025.

Emergency Intervention: Staff are trained in CPI techniques.

According to Title 22, deficiencies were observed and are cited in LIC9099D.



Exit interview was conducted and a copy of the report/appeal rights was issued to Administrative Assistant Denise Hicks.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2025 01:22 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/04/2025 at 01:06 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: 08/04/2025

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 the living room had a hole in the wall near the arch hallway and C1's room had 3 holes in the wall and the bottom part of the wall near the closet is dirty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Administrator shall submit picture proof evidence that all the holes C1's bedroom walls, and living room wall have been repaired. C1's room wall near the closet shall be cleaned.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 Administrator’s file was not available for review, and S3’s file was missing the personnel record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Administrator shall submit proof of their CPI, 1st Aid/CPR, Health Screening/TB, Personnel Record, and copy of Administrator Certificate. In addition, a copy of staff (S3's) Personnel Record shall be submitted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/04/2025 01:22 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/04/2025 at 01:06 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: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 because continuation education training documents were not available for review and training logs on site have not been updated, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2025
Plan of Correction
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Based on record review, the licensee did not comply with the section cited above in staff files were missing current continuing education training, which poses/posed a potential health, safety or personal rights risk to persons in care.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
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