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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601730
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:19:31 PM

Document Has Been Signed on 09/12/2023 03:19 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:CAPS ALZHEIMER'S DAY SERVICESFACILITY NUMBER:
198601730
ADMINISTRATOR:ELIZABETH NADEAUFACILITY TYPE:
775
ADDRESS:2501 E CORTEZ ST,N WING #14-16TELEPHONE:
(626) 917-4484
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 30CENSUS: 7DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Elizabeth NadeauTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual inspection at the facility. LPA met with staff Melodie Flores who allowed the entry of the facility explained the purpose of the visit. Shortly after, the program director Elizabeth Nadeau arrived and assisted with the visit. The facility is licensed to serve ambulatory adults age 18 and older.

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.

The following were observed:
The day program is located in a one (1)building with an outside activity area that includes the patio, program room, kitchen area, program director office and there are two public bathrooms (One for Men and One for Women) with fully functional appliances outside the CAP program which shared with West Covina Senior Center. The hot water temperature were measured within the range of 105 - 120 degrees F. There are no obstructions to the walkways and the facility is clean. Disinfectants and cleaning solutions are locked under the sink. The fire extinguishers were last inspected on 07/24/23. LPA also inspected the carbon monoxide detectors and they are working well. The facility has a rest area for the clients in the corner of the program room. For the patio, there's also a shaded area with tables and chairs for clients to utilized for the outdoor activity. The clients usually get their lunch through West Covina Senior Center and they are the one to prepare the food. The facility has a water dispenser and also adequate snacks for clients. Currently no client is taking medication at the day program. The facility continue to practices the infection control and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and checking staff temperature. The facility has an updated Infection Control Plan and COVID-19 mitigation plan in place.

(See LIC809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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: CAPS ALZHEIMER'S DAY SERVICES
FACILITY NUMBER: 198601730
VISIT DATE: 09/12/2023
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LPA reviewed 2 personnel files. The program director and staff have the annual training hours and health screening forms along with TB test results. They all have criminal background clearance and associated to the facility. The program director and the staff also has an updated First Aid and CPR certificate. LPA reviewed 3 Client files. The client files are located in the program director office and stored in a locked cabinet. The client files consist of the admission agreement, IPP/Appraisal Needs & Services Plan, and medical assessment with the TB results. Currently no client in the day program with any restricted health condition or any required postural support client
The facility has an updated Emergency Disaster Plan with relocation sites, shutoff valves, and local emergency contact numbers. The last fire drill was conducted on 09/05/23 and earthquake drill was conducted on 09/11/23.
The facility does not use any restraint on clients at the day program.

There are no deficiencies issued today. An exit interview was held and a copy of this report was given to Elizabeth Nadeau
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
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