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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602215
Report Date: 04/13/2022
Date Signed: 04/13/2022 01:42:48 PM

Document Has Been Signed on 04/13/2022 01:42 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:CENTER FOR BEHAVIORAL CHANGE 6FACILITY NUMBER:
198602215
ADMINISTRATOR:EBENEZER AKINOLAFACILITY TYPE:
735
ADDRESS:52 RISING HILL RDTELEPHONE:
(909) 461-3879
CITY:POMONASTATE: CAZIP CODE:
91766
CAPACITY: 4CENSUS: 3DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Facility AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with S-1 and explained the purpose of today's visit. Facility Administrator arrived at approximately 1:00 P.M and assisted with this visit.

All Clients residing at this facility receive case management services provided by San Gabriel Pomona Regional Center. This home has (4) bedrooms, (2) bathroom, living room, dining room, family room and attached garage.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed. Sings also posted inside the bathrooms.
  • PPE supplies observed. These items are stored inside the garage.
  • Hygiene supplies observed. Items stored inside the garage.
  • Bathrooms have hand soap, paper towels and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed. An additional refrigerator and freezer with additional food was observed inside the attached garage.
  • Per Administrator, (3) clients are fully vaccinated.
  • Per Administrator, staff are fully vaccinated.
  • Medication reviewed for (3) Clients (Client #1 through Client #3).
  • Clients were be socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Facility Administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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