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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601931
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:30:53 PM

Document Has Been Signed on 06/02/2022 04:30 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 @ PAYSONFACILITY NUMBER:
198601931
ADMINISTRATOR:MAGEE, LORINGFACILITY TYPE:
735
ADDRESS:18445 PAYSON STTELEPHONE:
(626) 331-2396
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 3DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Lead staff Sharina CapleTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an annual required visit. LPA met with Lead staff Sharina Caple and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility has an approved mitigation plan on file. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center.
LPA toured the home and inspected four (4) bedrooms, two (2) bathrooms, kitchen, dining room , living room, and attached garage. Laundry area is located in the garage. 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 seating area for the clients located in the backyard. LPA observed laundry detergent locked in the garage and not accessible to clients.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.
Client Bedrooms were checked. Each bedroom has a smoke/ carbon monoxide detector, bed, linen, dresser, light, and sufficient closet space. The bathrooms were toured. Bathrooms are clean and have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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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 @ PAYSON
FACILITY NUMBER: 198601931
VISIT DATE: 06/02/2022
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LPA observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Smoke/carbon monoxide detector was observed in the hallway and working properly. Fire extinguishers were fully charged and operational.

LPA reviewed client files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed.


Exit interview held. A copy of the report was provided to Lead staff

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

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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