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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600948
Report Date: 10/14/2024
Date Signed: 10/14/2024 12:28:25 PM

Document Has Been Signed on 10/14/2024 12:28 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/
DIRECTOR:		JUSTIN JOHNSONFACILITY TYPE:
735
ADDRESS:114 FAIRVIEW AVETELEPHONE:
(626) 576-0477
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 4CENSUS: 4DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Justin Johnson, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Galarza made an unannounced Required - 1 year annual inspection visit. The purpose of the visit was explained to staff Claudia Lopez. Administrator Justin Johnson arrived shortly after. The facility is licensed as a level 4N Adult Residential Facility (ARF) that serves developmentally disabled residents under age 59, and is vendored by Eastern Los Angeles Regional Center. The facility is a single story home located in a residential neighborhood. It consists of 4 resident bedrooms, 1 office room/laundry area, 2 bathrooms, kitchen, dining room, living room, outdoor patio, and a detached garage.
The following 12 (CARE) tool domains were utilized during the inspection.

Infection Control: The facility has a current Infection Control Plan.

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. A First Aid Kit and Manual were observed. The facility has 3 fully charged fire extinguishers. Hot water temperature readings did not measure between the required 105 - 120 degrees Fahrenheit. The kitchen sink measured 131.9 DF and bathrooms measured 136.7 DF & 135 DF. Storage areas for cleaning solutions/toxins, knives, and hazardous items were inaccessible to clients.

Operational Requirements: Fire clearance is approved for 2 ambulatory and 2 non-ambulatory residents. Care and supervision to meet the clients needs was observed. Residents use wheelchairs and walkers. Facility manages residents P & I monies. Facility has a current Surety Bond that expires Nov. 2024.



Staffing: A total of 11 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Four (4) staff files were reviewed. Criminal background clearance, continuing education of DSP training, 1st Aid/CPR training, CPI emergency training, and health screening/TB clearance.

***Note: Administrator certificate expired 4/11/2024 . Proof that documents are pending approval was provided.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: KAISER SPECIALIZED RESIDENTIAL FAIRVIEW
FACILITY NUMBER: 198600948
VISIT DATE: 10/14/2024
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Resident Rights/Information: Resident Personal Rights and HCBS House Values are posted. Internet access is available for residents. Physician's orders are on file. One resident requires a modified chopped diet.

Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Reports, IPPs, medical/functional assessments, TB clearance, personal rights, medical consent, medication records, Age Exceptions, 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, and COVID-19 vaccination cards on file. Staff training was reviewed.

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

The last Fire/Emergency Drill was conducted on 9/2/2024, within 6 months of Title 22 requirement.

Emergency Intervention: Facility utilizes CPI emergency training techniques.


Exit interview was conducted with Administrator Justin Johnson. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
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Document Has Been Signed on 10/14/2024 12:28 PM - It Cannot Be Edited


Created By: Noemi Galarza On 10/14/2024 at 11:58 AM
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: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients 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 the the hot water temperature in the bathrooms was 135 DF & 136.7 and kitchen sink measured 131.9 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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Administrator shall submit a hot water temperature log indicating the water was tested 3 times a day today and tomorrow. POC is due 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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024


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