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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603269
Report Date: 01/19/2023
Date Signed: 01/19/2023 04:30:24 PM

Document Has Been Signed on 01/19/2023 04:30 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 #8FACILITY NUMBER:
198603269
ADMINISTRATOR:JASON PIGGEEFACILITY TYPE:
735
ADDRESS:645 S. INMAN ROADTELEPHONE:
(323) 816-4462
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
01/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:LaTonya King TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met with DSP Chinasa Nwachukwu and explained the reason for the visit. Shortly after the administrator LaTonya King arrived. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: living room, dining room, sitting room, kitchen, office, four clients bedrooms, three bathrooms, laundry room, and a detached garage. All four clients bedrooms were toured. Each client bedroom has one bed, one night stand, one drawer, one chair, required bed linen and furniture and sufficient lighting and closet space. All 3 bathrooms were toured and they are all clean, sanitary and in a good working condition. The hot water temperature in all 3 bathrooms were tested from 110.4 to 117.5 degrees F which is within Tittle 22 regulation. The refrigerator in the kitchen and freezer in the garage have 2 days perishable food supply and the kitchen cabinet has the 7 days non perishable food supply. All appliances in the kitchen are working probably. The common area such as living room, sitting room and dining room have the required furniture. The front and back yard are maintained well and the back yard has a shaded area with chairs and table for client to utilize. All the sharp knives and utensils are locked in the cabinet in the office which inaccessible to clients.

LPA reviewed all four clients' files and confirmed all the emergency contact information are updated. LPA also reviewed two staff files are they are all background check cleared and they have the updated health screening in their personnel file. LPA also reviewed all four clients medication and they all seemed updated and accurate.

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, The facility is disinfected every shift, the bathrooms have sufficient soap, paper towels, and signs and PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit, Exit interview conducted and a copy of the report was provided to the administrator.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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