<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601730
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:47:32 PM

Document Has Been Signed on 07/23/2024 03:47 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:CAPS ALZHEIMER'S DAY SERVICESFACILITY NUMBER:
198601730
ADMINISTRATOR/
DIRECTOR:		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:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Alyssa Moran- Betancourt - Activity CoordinatorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual inspection visit at the facility using the CARE inspection tool. LPA met with Alyssa Moran- Betancourt - Activity Coordinator and explained the reason of the visit. Administrator was notified about the visit over the phone.
The Adult Day Program is approved to serve ambulatory adults ages 18 and older. Currently 11 clients in the day program. The day program consists of outdoor activity area, Arts and Crafts area, kitchen / dining area, Administrator office and 2 bathrooms (One for Men and One for Women). The facility has a rest area for the clients in the corner of the activity room. During the inspection LPA observed: Outdoor activity area observed dusty and not clean at the time of visit. Gardening tools (Poly leaf rake, Heavy duty hoe, Shovel) were observed in outdoor activity area unlocked and accessible to the clients. Safety pins and Steel utility knife were observed in the drawer in the kitchen area. Cabinet door was broken under the sink in the activity area. Lysol disinfectant spray, 409 Multi Surface Cleaner under sink cabinet in the kitchen area were unlocked and accessible to the clients. The water temperature was measured in both bathrooms and tested within 107.8 F - 114.2 F, which is within the required Title 22, California Code of Regulations. There are no obstructions to the walkways. There is no pool or large body of water at the premises. A fire extinguisher observed in the Arts and Crafts area and was fully charged. The smoke/carbon monoxide detector was observed in activity area, was tested, and observed to be fully operational. The last fire drill was completed in 6/21/2024. A first aid kit was observed in the facility with the required items and a first aid manual was available. There are storage cabinets for the clients belongings.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 07/23/2024 03:47 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2024 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: CAPS ALZHEIMER'S DAY SERVICES
FACILITY NUMBER: 198601730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Lysol disinfectant spray, 409 Multi Surface Cleaner were observed under sink cabinet in the ktchen area, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Lysol disinfectant spray, 409 Multi Surface Cleaner were locked immediately. No further action needed.
Type A
Section Cited
CCR
82087.2(a)(1)
Outdoor Activity Space
(a) If outdoor activity space is provided, it shall: (1) Be free of hazards.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed Gardening tools (Poly leaf rake, Heavy duty hoe, Shovel), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Gardening tools were locked immediately. No further action needed
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/23/2024 03:47 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2024 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: CAPS ALZHEIMER'S DAY SERVICES
FACILITY NUMBER: 198601730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087.3(a)
Indoor Activity Space
(a) The licensee shall ensure safe and healthy indoor activity space for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Safety pins and and Steel utility knife were observed in the drawer in the kitchen area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
The sharps immediately removed and placed in an inaccessible area. Corrected during visit.
Type B
Section Cited
CCR
82087(a)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Cabinet door was broken under the sink in the activity area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
1
2
3
4
Facility will repair the cabinet door and send proof to LPA by POC 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/23/2024 03:47 PM - It Cannot Be Edited


Created By: Nune Margaryan On 07/23/2024 at 02:10 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: CAPS ALZHEIMER'S DAY SERVICES
FACILITY NUMBER: 198601730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087.2(a)(2)
Outdoor Activity Space. (a) If outdoor activity space is provided, it shall: (2)Provide a shaded rest area for the clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed that there is a outdoor activity area was dusty and not clean, and shaded area not provided for the clients for aotdoor activities, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
1
2
3
4
The licensee will clean the outdoor activity are and ensure that shaded outdoor activity area will ready for the clients.
Proof will be provided to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: CAPS ALZHEIMER'S DAY SERVICES
FACILITY NUMBER: 198601730
VISIT DATE: 07/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food is not prepared at this program and clients usually get their lunch through West Covina Senior Center. Refrigerator was observed at the facility, to be operational and used for consumer snacks, drinks, and any food they may bring that needs to be stored.
LPA reviewed 2 staff files. Staff had criminal background clearance and associated to the facility. Staff also has an updated First Aid and CPR certificate. LPA reviewed 4 Client files. The client files are located in the Administrator 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.

During today’s inspection deficiencies observed. See 809D for details.

An exit interview was conducted, and a copy of the report was provided along with appeal rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5