198601931-5-10-2023-28-AS-THEA-CRPLKH-20230510084933

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601931
Report Date: 05/09/2023
Date Signed: 05/10/2023 08:51:21 AM

Document Has Been Signed on 05/10/2023 08:51 AM - 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:	FLAGSHIP @ PAYSON		FACILITY NUMBER:	198601931
ADMINISTRATOR:	MAGEE, LORING		FACILITY TYPE:	735
ADDRESS:	18445 PAYSON ST		TELEPHONE:	(626) 331-2396
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY: 4		CENSUS: 3	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Loring Magee		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Loring Magee (Administrator) who assisted with the visit. The facility is licensed to serve 4 non-ambulatory clients ages 18 to 59 years old.

The facility is a single-story home located in a residential. A tour of the facility includes: dining room, kitchen, living room, 4 client bedrooms, 1 office, 2 bathrooms, attached garage, front yard, and backyard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance.

Physical Plant & Environment Safety: There are 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, attached garage, front yard and backyard. All bathrooms are clean, operational and observed with shower mats. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested in the bathroom and kitchen measuring at 105.8 – 113.9 degrees F which are within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to clients. The last Fire/Emergency Drill was conducted on 05/02/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the kitchen area and is fully charged.

(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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: FLAGSHIP @ PAYSON	FACILITY NUMBER: 198601931
	VISIT DATE: 05/09/2023

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Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

Due to time restraints LPA Tena Herrera could not complete the annual inspection. LPA will return to finish remaining 6 domains at a later date.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held, due to technical issues a copy of the report was emailed to administrator Loring Magee on 5-10-23.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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