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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600769
Report Date: 09/08/2025
Date Signed: 09/08/2025 01:22:46 PM

Document Has Been Signed on 09/08/2025 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:BEHAVIOR EDUCATION & LEARNING INSTITUTEFACILITY NUMBER:
198600769
ADMINISTRATOR/
DIRECTOR:		DANIELLE BERGERFACILITY TYPE:
775
ADDRESS:1919 PALM AVETELEPHONE:
(626) 457-8718
CITY:ALHAMBRASTATE: CAZIP CODE:
91803
CAPACITY: 75CENSUS: 49DATE:
09/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:03 AM
MET WITH:Danielle Berger, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:20 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 Adult Program Director Ruth Lemus. Administrative Assistant Susan Lujan and Executive Director Danielle Berger arrived later and assisted with the visit. The Day Program is licensed to serve 75 developmentally disabled adults; vendored by Eastern Los Angeles Regional Center. The facility provides transportation services, and is equipped with 5 large vans and 3 small vans. Facility provides Community Inclusion Services programming.

The following were observed/inspected:



Infection Control: An Infection Control Plan was submitted to CCL and was available on site for review.

Physical Plant/Environment Safety: Facility is a one story building. The program consists of 3 classrooms, main room, 2 offices, kitchen, outdoor patio with basketball court, outdoor shaded patio area, 5 restrooms, and storage rooms. Three (3) restrooms are ADA approved to accommodate non-ambulatory persons in wheelchairs. Electrical smoke and sprinklers, and carbon monoxide detectors were observed. The facility has 8 fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients. Water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. First aid kits are kept in activity rooms and office, consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. A 1st Aid Manual is needed. The facility's last fire inspection was conducted on 7/2/2024.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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: BEHAVIOR EDUCATION & LEARNING INSTITUTE
FACILITY NUMBER: 198600769
VISIT DATE: 09/08/2025
NARRATIVE
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Operational Requirements: Fire clearance is approved for 67 ambulatory clients and 8 non-ambulatory developmentally disabled adults. Care and supervision to meet the clients needs was observed. No special equipment is needed by any of the clients. Liability insurance expires 11/11/2025. The facility does not handle client's monies and does not have a Surety Bond.

Staffing: A total of 18 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Six (6) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, certifications, staff training, and 1st Aid/CPR training.

Client Rights/Information: Personal rights were posted and in client files.

Client Records/Incident Reports: Eight (8) client files were reviewed. They contained ISP, IPP, medical assessments, and TB clearance. All 8 files had outdated IPP reports.

Food Service: There is a prep kitchen that provides food to clients who do not bring their own lunch and/or snacks. It was observed to be clean and sanitary. All sharps were locked.

Health Related Services: There are no centrally stored medications because the facility does not administer client medications. PRN log is in place.

Incident Medical and Dental: All clients have Individual Services Plans on file. Staff training was observed.

Disaster Preparedness, and Emergency Intervention: The facility has an updated Emergency Disaster Plan LIC 610D containing emergency evacuation information. An emergency drill was conducted on 9/4/2025, within the last 6 months as required. The facility conducts monthly emergency drills addressing different training topics.

Emergency Intervention: No manual restraints or seclusion are used with clients in care.

Per Title 22, deficiencies were observed. See LIC 9099D pages.


Exit interview conducted with Executive Director Danielle Berger. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/08/2025 01:22 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/08/2025 at 12:33 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: BEHAVIOR EDUCATION & LEARNING INSTITUTE
FACILITY NUMBER: 198600769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 bathrooms and kitchen sinks measured between 86.9 DF - 137.4 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Executive Director agreed to adjust the hot water temperature and submit a hot water temperature log by tomorrow.
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: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2025 01:22 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/08/2025 at 12:33 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: BEHAVIOR EDUCATION & LEARNING INSTITUTE
FACILITY NUMBER: 198600769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

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 8 client files were reviewed and all had IPP reports that were more than 3 years old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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Executive Director agreed to contact Regional Centers and obtain the most updated IPP reports for clients (C1-C8). Submit copies of client IPPs by POC due date.
Type B
Section Cited
CCR
82075(g)(1)(A)
Health-Related Services
If the day program has no medical unit at the program site, first aid supplies shall be maintained and be readily available in a central location. (1) The supplies shall include at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
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 program does not have a !st Aid Manual; they only had a 1st Aid gudie, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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Executive Director agreed to submit proof that a 1st Aid Manual was purchased.
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: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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