198602585-8-19-2023-28-AS-CWOG-CUTVG5-20230818162459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602585
Report Date: 08/18/2023
Date Signed: 08/19/2023 06:36:34 PM

Document Has Been Signed on 08/19/2023 06:36 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:	CENTER FOR BEHAVIORAL CHANGE #5		FACILITY NUMBER:	198602585
ADMINISTRATOR:	LATONYA KING		FACILITY TYPE:	735
ADDRESS:	2111 EAST GARVEY AVE NORTH		TELEPHONE:	(626) 502-1424
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Latonya King		TIME COMPLETED:	04:40 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 (LPAs) Christine Wong and Nune Margaryan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Abraham Oketona and explained the reason of the visit. Shortly after, the administrator Latonya King arrived and assisted with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59. 4 Ambulatory of which 1 may be non-ambulatory. The facility is licensed as a specialized home vendored by San Gabriel Pomona Regional Center. The following twelve (12) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing and self symptom check of staff. The facility has an Infection Control Plan and COVID-19 mitigation plan in place. 2. Physical Plant and Environmental Safety: The facility is a single story house and located at the residential neighborhood area. The facility includes: dining area, kitchen, family room, four clients bedrooms and two clients bathrooms and a detached garage. Each client bedroom has one bed, one chair, night stand, drawer, required bedding and sufficient lighting and closet space. The two clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in the two bathrooms are between 105 and 105.6 degrees F. The sharp knives and utensils are locked in the medication cabinet. All the chemicals and cleaning supplies are stored and locked under the sink and cabinet in the garage and they are inaccessible with clients. The extra linen are stored in the hallway cabinet and extra personal hygiene are stored in the garage cabinet. The facility has a hallway light which is always on during night time and clients can have access to the bathroom. The facility has a land line telephone system. LPA inspected the carbon monoxide detectors and smoke detectors and they are all operational. The passageway, walkway and patio are free of obstruction.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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: CENTER FOR BEHAVIORAL CHANGE #5	FACILITY NUMBER: 198602585
	VISIT DATE: 08/18/2023

NARRATIVE

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3. Operational Requirements: The facility is approved for four (4) ambulatory which one may be non-ambulatory. Currently all clients are ambulatory. The last fire and earthquake drill was conducted on 7/05/23. The facility has a covered patio with table and chairs for client to utilized for outdoor activity. The facility would all also let client to attend community activities if there's an opportunity or if client wanted.

4. Staffing: Facility has a sufficient staffing in the facility.LPA also reviewed the night shift staff and the staff has the updated training for the facility planned emergency procedure.

5. Personnel Records-Training: All the staff files are stored in the locked cabinet in the garage. LPA reviewed all staff files are they do have the required documents in their personnel files which includes updated required training hours, first aid certificate, health screening and TB test result. The facility administrator is Latonya King and her administrator certificate will be expired on Sept,2024 and also has the required HIV and TB training causes in file. All the staff are over 18 years old, criminal background check cleared and associated with the facility.

6. Client's Right-Information : Currently the facility has no client required postural support. The facility does serve adults has internet service shall provide at least one access device.

7. Clients Records-Incident Reports: All clients files are stored and locked in the medication cabinet near the entrance area. LPA reviewed all four (4) clients files and all have the required documents which include face sheet, updated physician report, admission agreement, functional capability Assessment, ambulatory status, TB test, medication list and Individual Program Plan (IPP).

8. Food Service: The facility has sufficient food supply include minimum two days perishable and seven days non perishable. All the food are stored probably. No clients in the facility is required modified diet. There are two refrigerators in the facility, one in the kitchen and one in the garage for additional food storage. The refrigerator is also maintained within the required temperature.

9. Health Related Services: The medication is centrally stored in the medication cabinet near the entrance way. LPA inspected all four (4) clients medication and medication administration record (MARs) and all seemed accurate and up-to-dated.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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: CENTER FOR BEHAVIORAL CHANGE #5	FACILITY NUMBER: 198602585
	VISIT DATE: 08/18/2023

NARRATIVE

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10. Incident Medical Services: The facility does not have any clients with Prohibited Health Condition or restricted health condition at the present time.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610D) dated on 7/25/23. The last emergency disaster drill was conducted on 7/05/23 and the facility has two alternative temporary shelter location.

12. Emergency Intervention: The facility does not use any restraint on any clients but all the staff has an updated Pro-Act training hours.

No deficiencies were observed during today's visit.

Exit Interview conducted. A copy of the report was provided to the administrator Latonya King

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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