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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601301
Report Date: 05/09/2024
Date Signed: 05/09/2024 01:34:47 PM

Document Has Been Signed on 05/09/2024 01:34 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:AIM HIGHER COVINAFACILITY NUMBER:
198601301
ADMINISTRATOR/
DIRECTOR:		GUADALUPE RODRIGUEZFACILITY TYPE:
775
ADDRESS:440 SOUTH CITRUS AVETELEPHONE:
(626) 339-0400
CITY:COVINASTATE: CAZIP CODE:
91723
CAPACITY: 80CENSUS: 51DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Amiel SalgadoTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Wong conducted an unannounced annual inspection at the facility. LPA met with Amiel Salgado (Program Director) and explained the purpose of the visit. The facility is licensed to serve SERVE EIGHTY (80) DEVELOPMENTALLY DISABLED ADULTS AGES 18 AND ABOVE. TWENTY (20) CLIENTS MAY BE NON-AMBULATORY.

LPA utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Infection Control, Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Reports-Training, Client Rights - Information, Client Records-Incident Report, Food Services, Health Related Services, Incidental Medical Services, Disaster Preparedness, Emergency Intervention.

1. Infection Control: Facility has an updated infection control plan in place, Facility continues to practice the infection control in the facility. Facility also has sufficient PPE supplies in the facility.

2. Physical Plant and Environmental Safety: The day program included: Lobby, conference room, life skills room, Staff break room, art room, vocational room, outing room, quiet room/changing room and administrator office and one men and one women restrooms. LPA inspected the restrooms and they are sanitary, clean and in a good working condition. The hot water temperature in both restrooms were tested between 107.4 and 119.4 degrees F which is within the Title 22 regulation. All chemicals and cleaning supplies are stored and locked in a cabinet near the art room. All the sharp knives are stored and locked under the sink in the staff break room. LPA inspected the carbon monoxide detector and it's working well. The passageway and walkway are free of obstruction. The facility has a water dispenser machine for client to have the drinking water.

3. Operational Requirements: The facility is licensed for 80 developmentally disabled adults aged 18 and above and 20 may be non-ambulatory. Currently there are only 7 clients in the facility are non-ambulatory which is within the fire clearance requirement.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: AIM HIGHER COVINA
FACILITY NUMBER: 198601301
VISIT DATE: 05/09/2024
NARRATIVE
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4. Staffing: There's sufficient staffing in the facility. The regional center required 4: 1 ration for clients to staff. The facility always has at least two staff on duty at all times.

5. Personnel Record-Training: All the staff in the facility are 18 years old with fingerprinted and associated with the facility. All the staff have the updated health screening and TB test result and the updated first aid certificate. LPA observed the program director does not have minimum 30 clock hours for continue education for every 24 months of employment.

6. Client Records: All the client's file are stored in the administrator office. All client have the required documents in file which include: face sheet, physician report with TB test result, admission agreement and IPP except three clients (C1-C3). Their IPP were not updated.

7. Client's Right Information: Currently the facility has no client required postural support. The client's right is always reviewed during the meeting annually.

8. Food Service: The clients usually bring their lunch and snacks to the facility daily and staff would assist clients to heat up the food from the microwave and the facility has a water dispenser which is available for client to use.

9. Health Related Services: Currently there's one client administered medication by staff. LPA reviewed the medication and its stored in the locked cabinet in the administrator office. LPA observed the medication and the Medication Administration Record (MAR) and it's accurate and updated. All staff in the facility also has an updated First Aid and CPR certificate.

9. Incidental Medical Services: Currently the facility has no client with any restricted health condition. There's one client who has diabetes but client is capable to perform her own glucose testing.

10. Disaster Preparedness: The facility has an updated emergency disaster plan and dated on 11/30/23. The last disaster drill was conducted on 3/8/24

11. Emergency Intervention: The facility does not use any restraint on clients.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2024 01:34 PM - It Cannot Be Edited


Created By: Christine Wong On 05/09/2024 at 01:04 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: AIM HIGHER COVINA
FACILITY NUMBER: 198601301

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82064(d)
Administrator -Qualifications and Duties
(d) The administrator shall receive and document a minimum of 30 clock hours of continuing education every 24 months of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed the program director does not have minimum clock hours of continuing educaiton every 24 months of employment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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The program director will send me the 30 clock hours of continuing education to LPA by POC due date.
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, LPA observevd Client#1 to Client#3 do not have the updated IPP in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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The program director will send LPA the updated IPP for clients by POC 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: AIM HIGHER COVINA
FACILITY NUMBER: 198601301
VISIT DATE: 05/09/2024
NARRATIVE
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Deficiency was cited.

Exit interview was conducted with Program Director. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4