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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601931
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:46:57 PM

Document Has Been Signed on 04/26/2024 03:46 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/
DIRECTOR:		MAGEE, LORINGFACILITY TYPE:
735
ADDRESS:18445 PAYSON STTELEPHONE:
(626) 331-2396
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 4CENSUS: 4DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Calvin CampbellTIME 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 Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with staff Calvin Campbell and explained the reason for the visit. Shortly after Administrator Loring Magee arrived to assist with the visit.

The physical plant was inspected along with medications, food supply, and client and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center. 3 clients were at the Day program at the time of visit and one client was in the school.


The facility is a single-story home located in a residential area. LPA toured the home and inspected dining room, living room, kitchen, 4 client bedrooms, 1 office, 2 bathrooms, attached garage, front yard, and backyard. 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 / Picnic table with benches and umbrella, for the clients located in the backyard. Laundry was observed in the garage. LPA observed laundry detergent locked in the cabinet in the garage and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the living room area which is covered by a screen. Client bedrooms were checked. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. Extra linens, blankets, towels, and personal hygiene supplies were observed in the hallway cabinet. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured 114.5 F. 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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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 2
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: 04/26/2024
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
 The fire extinguisher was observed in the kitchen area and is fully charged. LPA observed the centrally stored medication cabinet to be locked in the office and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Smoke detectors and carbon monoxide detectors were observed in the clients rooms and in the hallways and working properly. LPA reviewed resident 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.

No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided to Loring Magee.

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

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2