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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601928
Report Date: 04/11/2024
Date Signed: 04/11/2024 05:33:48 PM

Document Has Been Signed on 04/11/2024 05:33 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:FLAGSHIP @ YALETONFACILITY NUMBER:
198601928
ADMINISTRATOR/
DIRECTOR:		MAGEE, LORINGFACILITY TYPE:
735
ADDRESS:206 N YALETON AVETELEPHONE:
(626) 502-1250
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Jackson Darvis - staffTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Jackson Darvis who assist with the visit. LPA explained the reason for the visit. Administrator Magee Loring arrived shortly after.

This is a single-story home located in a residential neighborhood. This home consists of (4) bedrooms, (2) bathrooms (one is share between to bedrooms) living room, kitchen, dining area and detached garage. Laundry observed in the garage. The facility is approved for four (4) non ambulatory developmentally disabled adults, ages 18-59. There are currently four (4) clients residing in this facility and receive services from San Gabriel/Pomona Regional Center.

The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded sitting area in the back of facility. Client bedrooms and bathrooms were checked. Each bedroom is equipped with the proper furnishings. Bedrooms also have sufficient closet space. LPA observed that Client bedrooms windows are dirty and blinds are broken in all bedrooms. The bathrooms are clean and have the required hygiene items. The hot water temperature was tested and was measured at 114.2 degrees F. Trash bins in the bathrooms were observed without covers. Gallon of Bleach observed under the sink in the share bathroom unlocked. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked and are inaccessible to clients. Hot water temperature tested in the kitchen and was measured at 116.4 degree F. LPA observed cleaning solutions/disinfectants are stored and locked under the snick in the kitchen. Fire extinguisher observed in the dining room fully charged. Carbon monoxide/smoke detectors in the hallway and in the client rooms are operational.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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Document Has Been Signed on 04/11/2024 05:33 PM - It Cannot Be Edited


Created By: Nune Margaryan On 04/11/2024 at 04:20 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: FLAGSHIP @ YALETON
FACILITY NUMBER: 198601928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above. LPA observed gallon of Bleach in the clients bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2024
Plan of Correction
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Licensee removed the Bleach and lock it in the Garage / Laundry.
No further action needed.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/11/2024 05:33 PM - It Cannot Be Edited


Created By: Nune Margaryan On 04/11/2024 at 04:20 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: FLAGSHIP @ YALETON
FACILITY NUMBER: 198601928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility 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
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Based on observation, the licensee did not comply with the section cited above. Facility / Clients bedrooms windows are dirty, blinds are broken in all bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Lisensee will deep clean the facility and purchace / repair the blinds in the clients bedrooms. Photos will be send to LPA by the POC due date.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

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. Thash bins in the clients bathrooms don't have covers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee will purchase trash bins with covers and replaced them. Photos will be send to LPA 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: FLAGSHIP @ YALETON
FACILITY NUMBER: 198601928
VISIT DATE: 04/11/2024
NARRATIVE
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The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the hallway. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.

Observed deficiencies are documented on 809D.

Exit interview conducted with Magee Loring and the copy of the report and appeal rights are provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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