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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600948
Report Date: 07/12/2022
Date Signed: 07/12/2022 04:44:28 PM

Document Has Been Signed on 07/12/2022 04:44 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:KAISER SPECIALIZED RESIDENTIAL FAIRVIEWFACILITY NUMBER:
198600948
ADMINISTRATOR:SERGIO CALDERONFACILITY TYPE:
735
ADDRESS:114 FAIRVIEW AVETELEPHONE:
(626) 576-0477
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 4CENSUS: 4DATE:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Lilia Dunn, House ManagerTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Josefina Untalan and explained the purpose of the visit. Administrator Sergio Calderon was explained the purpose of the visit telephonically. House Manager Lilia Dunn arrived shortly after to assist with the visit. There are four (4) level 4h developmentally disabled clients in the home; of which 2 can be non-ambulatory. The facility is licensed for clients 18-59 years old. However, there are 3 residents over the age of 60, which exceeds 50% of census. The licensee must request an exception in order to accept or retain the individual.
The facility is a single story home located in a residential neighborhood. It consists of 4 client bedrooms, 2 bathrooms, kitchen, living room/dining area, shaded patio furniture, and detached garage. The last emergency disaster drill was conducted on 7/11/2022. Administrator certificate expires 11/15/2023.

Observations:
  • COVID-19 Infection Control signs were observed in the entrance and bathrooms. Screening protocols are in place. Clients in care do not wear a mask because it is not tolerated due to cognitive impairment.
  • Each client bedroom is designated as a COVID-19 isolation room if needed.
  • Four (4) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked closet.
  • Sharps and chemicals/cleaning supplies are stored inaccessible to residents.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed. Smoke detectors were tested and are operational. Fire extinguishers are fully charged. The facility has a fire pull alarm system.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Client files were reviewed. Medical/Specialist Visit Information documents were obtained.
  • All residents in care were observed to have extremely short hair cuts that appear shaven. Per documentation, "clean short haircut for personal hygiene" was ordered by MD. However, facility did not obtain consent from responsible parties, and the San Gabriel Regional Center stated they were not aware.
Deficiencies are being cited. See LIC 809D.
Exit interview was conducted with House Manager Lilia Dunn. A copy of the report/appeal rights was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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 07/12/2022 04:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/12/2022 at 04:15 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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. 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 above in that there are a total of 3 clients over the age of 59, and an Exception Waiver for clients is not in place. In the past there were 2 clients over the age of 59; at that time and Exception Waiver was not needed. However, now the census exceeds 50% of allowable residents over the age of 60, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 08/09/2022
Plan of Correction
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Administrator shall submit an Exception request for R1, R2, & R3 by POC due date, and/or one of the clients shall be relocated. If an extension is required submit a written request by the due date.

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: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/12/2022 04:44 PM - It Cannot Be Edited


Created By: Noemi Galarza On 07/12/2022 at 04:23 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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(3)
Personal Rights
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed all 4 clients were observed to have very short hair appearing to be shaven; 3 out of the 4 clients are non-verbal with severe intellectual disability. Responsible party's consent was not provided and the SGPRC was contacted and not aware of this. MD note states "short haircut for personal hygiene", but no history of head lice was provided;
which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2022
Plan of Correction
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Administrator shall submit a written statement of how this deficiency was corrected, and provide proof of responsible party consent by POC due date.
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: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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