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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600948
Report Date: 10/17/2022
Date Signed: 10/17/2022 03:23:28 PM

Document Has Been Signed on 10/17/2022 03:23 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
GREATER LA AC/SC, 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:
10/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Interim Administrator Mohammed ShiraziTIME COMPLETED:
01:06 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez and Noemi Galarza conducted a Case Management -Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20221010151359 visit. The purpose of the visit was explained to Interim Administrator Mohammed Shirazi.

On 10/17/2022 LPAs observed a lilac recliner laying on it's side behind the ramp walkway railing. The recliner had spider webs and staff stated it had been discarded behind the ramp walkway area months ago. Per Interim Administrator Shirazi, local city waste management will be picking up the discarded recliner on 10/21/2022.

Per Title 22, Division 6, Chapter 1, Article 07. Buildings and Grounds 80087(b) "All clients shall be protected against hazards within the facility through provision of the following: (c) "All outdoor and indoor passageways, stairways,inclines,ramps,open porches and other areas of potential hazard shall be kept free of obstruction."

During the interview process with Staff (S1) it was discovered that S1 tested positive for COVID-19 on 9-29-22 and returned to work on 10-10-22. The department did not receive a SIR about this positive staff COVID-19 case. Per Interim Administrator Shirazi, he was not aware that staff testing positive with COVID-19, must also be reported to the department.

Per Title 22, Division 6, Chapter 1, Article 06. Reporting Requirements 80061(b) "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."

Deficiencies are cited. See LIC 809D.
Exit interview was held with Interim Administrator Mohammed Shirazi. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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 10/17/2022 03:23 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 10/17/2022 at 12:24 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: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2022
Section Cited
CCR
80087(b)

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80087(b).Buildings and Grounds. All clients shall be protected against hazards within the facility through provision of the following: (c) "All outdoor and indoor passageways, stairways,inclines,ramps,open porches and other areas of potential hazard shall be kept free of obstruction."
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Per Interim Administrator Mohammed Shirazi, local waste management is scheduled to remove the discraded recliner on 10-21-22.

Submit picture proof that the item was removed.
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This requirement was not met evidence by:
Based on physical plant observation, the recliner was laying it's side behind a ramp walkway.

This poses a potential health and safety risk to clients in care.
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Type B
10/31/2022
Section Cited
CCR80061(b)

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80061 (b) 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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All staff and residents who test positive for COVID-19 must be reported to CCLD on a SIR. Per Interim Administrator Mohammed Shirazi, he will submit a SIR to CCLD immediately.
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This requirement was not met evidenced by: Based on record review, the facility failed to report a staff positive COVID-19 case. S1 tested positive on 9/29/22. This poses a potential health and safety risk to clients 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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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