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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602585
Report Date: 08/12/2022
Date Signed: 08/12/2022 04:58:56 PM

Document Has Been Signed on 08/12/2022 04:58 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 #5FACILITY NUMBER:
198602585
ADMINISTRATOR:LATONYA KINGFACILITY TYPE:
735
ADDRESS:2111 EAST GARVEY AVE NORTHTELEPHONE:
(626) 502-1424
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
08/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Staff Ohia LoyceTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with staff Ohia Loyce and explained the reason for the visit. Administrator Latonia King arrived at 2:50pm and assist with 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. Facility submitted mitigation on 06/29/21. The facility is licensed to serve developmentally disable clients between the ages 18 to 59. There are currently 4 clients residing at the home and receive services from San Gabriel / Pomona regional Center. The facility is located in a residential area. LPA toured the home and inspected living room, dining area, kitchen, 4 bedrooms, 2 bathrooms and attached garage / office. Laundry area was observed in the garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area / patio for the clients located in the backyard. Passageways and exits are free of obstruction. LPA observed laundry detergent, cleaning solutions/disinfectants are stored and locked in the garage. 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 is equipped with the proper furnishings. Bedrooms also have sufficient closet space. The bathrooms were toured. Bathrooms are clean and have the required hygiene items. 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 and are inaccessible to clients.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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: CENTER FOR BEHAVIORAL CHANGE #5
FACILITY NUMBER: 198602585
VISIT DATE: 08/12/2022
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The fire extinguisher observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. LPA observed 2 cameras: one in the living room and one on the outside of the facility, however, no cameras in any personal areas inside the home. LPA observed the centrally stored medications 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.

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.


No deficiency was observed during today's visit. Exit interview was conducted with the House Manager and a copy of report was provided.

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

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC809 (FAS) - (06/04)
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