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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600754
Report Date: 08/19/2022
Date Signed: 08/19/2022 04:17:22 PM

Document Has Been Signed on 08/19/2022 04:17 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:
08/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Jason PiggeeTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza attempted to conduct an unannounced Required 1-year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Lamont Greenlea and explained the purpose of the visit. Mr. Greenlea informed LPA that there are active COVID-19 cases in the facility. LPA spoke to Administrator Jason Piggee telephonically.

Administrator confirmed there are 2 clients and 1 staff that tested positive for COVID-19. Client (C1) & client (C2) tested positive on 8/11/22. Staff (S1) tested positive on 8/16/22. Administrator stated that the incident reports were faxed. However, LPA verified with Regional Office and no incident reports have been received via fax or email as of this morning.
    Per Title 22, 80061(b). Reporting Requirements. Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
Administrator was instructed to send via fax CCL Regional Office the COVID-19 incident reports today.

LPA will return at a later date to conduct the annual inspection.

Per California Code of Regulations, Title 22, a deficiency was cited. See LIC 809D.

A telephonic exit interview was conducted with Administrator Jason Piggee. A copy of the report and appeal rights were issued. Mr. Piggee was instructed to sign and email back the signed report.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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 08/19/2022 04:17 PM - It Cannot Be Edited


Created By: Noemi Galarza On 08/19/2022 at 04:01 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: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2022
Section Cited
CCR
80061(b)

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Reporting Requirements. Reporting Requirements. Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator shall fax an incident report to CCL and report to LA County Department of Public Health the 2 client and 1 staff COVID cases.



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This requirement was not met evidenced by:

LPA visited the facility today and learned that there are active COVID-19 cases in the home. Clients (C1 & C2) tested positive on 8/11/22 & staff (S1) tested positive on 8/16/22. This poses an immediate health and safety risk to residents in care.
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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: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
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