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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603269
Report Date: 01/07/2025
Date Signed: 01/07/2025 04:59:06 PM

Document Has Been Signed on 01/07/2025 04:59 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/
DIRECTOR:
JASON PIGGEEFACILITY TYPE:
735
ADDRESS:645 S. INMAN ROADTELEPHONE:
(323) 816-4462
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 4CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:39 PM
MET WITH:Latonya King, Assistance AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:02 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP David Alekhuogie who allowed the entry of the facility and LPA explained the purpose 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 to 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 (3) tool domains were observed and reviewed: Infection Control, Physical Plant/Environmental Safety, and Food Service.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility still encourages hand washing. 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 111.0 and 118.9 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.

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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: 01/07/2025
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(Continued from 809)

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.

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.


No deficiencies were observed during this visit. LPA will return on a later day to complete inspection.

Exit Interview conducted and a copy of the report was provided to Assistant Administrator Latonya King.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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