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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601931
Report Date: 05/22/2023
Date Signed: 05/22/2023 04:26:01 PM

Document Has Been Signed on 05/22/2023 04:26 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:FLAGSHIP @ PAYSONFACILITY NUMBER:
198601931
ADMINISTRATOR:MAGEE, LORINGFACILITY TYPE:
735
ADDRESS:18445 PAYSON STTELEPHONE:
(626) 331-2396
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 3DATE:
05/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Loring MageeTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual continuation 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.

LPA inspected the remaining four domains using the Compliance and Regulatory Enforcement (CARE) tools for which include the following:

Operational Requirements: There are currently 3 non-ambulatory clients residing at the facility.


Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Loring Magee certificate expires on 01/2024.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in office. Staff have current CPR/first aid training and sufficient on-going training.
Resident Rights-Information: Clients personal rights poster is posted in the dining area. The facility provides internet and telephone access for the clients in care.
Resident Records-Incident Reports: Client files are kept locked in the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Health Related Service: Staff designated to administer medication has the proper annual training on file. During the visit today, LPA reviewed all 3 clients' medication with no issues observed.
Incidental Medical & Dental: Medication is centrally stored in a locked staff office and inaccessible to other clients. All medication are in their original containers.
During todays visit LPA conducted 3 staff interviews and 3 client interviews.
Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to the Administrator Loring Magee.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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