198603269-2-15-2024-28-AS-CWOG-D2GRMK-20240215120853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603269
Report Date: 02/15/2024
Date Signed: 02/15/2024 12:09:39 PM

Document Has Been Signed on 02/15/2024 12:09 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 #8		FACILITY NUMBER:	198603269
ADMINISTRATOR:	JASON PIGGEE		FACILITY TYPE:	735
ADDRESS:	645 S. INMAN ROAD		TELEPHONE:	(323) 816-4462
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY: 4		CENSUS: 4	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Latonya King		TIME COMPLETED:	12:40 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 Analyst (LPA) Christine Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP Quadri Adisa who allowed the entry of the facility and explained the reason of the visit. Shortly after, Assistant Administrator Latonya King arrived and assisted LPA with the visit. The facility is approved for serve Developmentally Disabled Adults AGE RANGE 18 THROUGH 59. 4 Non-ambulatory and approved for Delayed Egress. The facility is vendorized as Level 4 Home with 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 temperature check for clients and 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 in a residential neighborhood area. The facility includes: living room, family room, dining area, kitchen, staff/visitor bathroom, two clients bathrooms, four clients bedrooms, administrator office, laundry room and a detached garage. All four clients bedrooms have one bed, one chair, one night stand, required beddings and furniture, sufficient lighting and closet space. All clients bathrooms are clean, sanitary and in a good working condition. The hot water temperature in both clients bathrooms were tested between 113.5 and 118.5 degrees F which is within the Title 22 regulation. All the kitchen appliances are working properly. The sharp knives and utensils are stored locked in the administrator office. The cleaning supplies are stored and locked in the storage room near the kitchen.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 #8	FACILITY NUMBER: 198603269
	VISIT DATE: 02/15/2024

NARRATIVE

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The extra linen and towels are stored in a storage room near the administrator office. Client's extra personal hygiene products are stored in the administrator office. The hallway night will be always on at night so client can use the non-private bathrooms. The facility has a telephone services on the premises. The passageway and patio are free of obstruction. LPA inspected the carbon monoxide detectors and they are working well.

3. Operational Requirements: Currently all the clients in the facility are ambulatory which is within the fire clearance approved. The last fire drill was conducted on 1/29/2024. The facility has a covered patio with table and chairs for client to utilized for outdoor activity. The facility would also let client to attend community activities if there's an opportunity or if client wanted.

4. Staffing: The facility has sufficient staffing in the facility. The NOC shift staff has the required facility planned emergency procedure training.

5. Personnel Records-Training: All the staff files are stored in the administrator office. All the staff in the facility are over 18 years old, background check cleared and associated with the facility. LPA inspected three staff files and all have the required documents which included: health screening, TB test result, required training hours and updated first aid/CPR certificate. The facility administrator is Latonya King and her administrator certification will be expired on 09/26/2024 and she has the required HIV and TB training certificate in file.

6. Client's right: Currently no client in the facility required any postural support. The facility does serve adults has internet service shall provide at least one access device for client to use video call with their families or day program.

7. Food Service: The facility has ample supply of 2 days perishable and 7 days non perishable food supply in the facility. The facility provide at least three meals a day and snacks too. All the food are stored properly in the refrigerator and kitchen. The refrigerator temperature is within the required temperature.

8. Client Records-Incident Reports: All clients files are stored in the administrator office. LPA inspected all four clients files and they all have the required documents including: face sheet, admission agreement, Individual Program Plan (IPP), updated physician report and TB Test result, functional capacity assessment, medication list and ambulatory status.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 #8	FACILITY NUMBER: 198603269
	VISIT DATE: 02/15/2024

NARRATIVE

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9. Health Related Services: Client's medication is centrally stored and locked in the administrator office and LPA inspected all four clients medication and they all seemed updated and accurate. All clients has 30 days supply of medication. The facility also provides transportation to client's medical and dental appointment.

10. Incidental Medical Services: Currently there are no clients who require health services or have a health condition that need to be monitored more carefully.

11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC 610D) in place. The facility conducted fire and disaster drill every 3 months. The last fire/disaster drill was conducted on 1/29/24. The facility has two alternative shelter location. The staff also trained annually for the emergency disaster plan.

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

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to Assistant Administrator Latonya King.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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