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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603269
Report Date: 02/18/2025
Date Signed: 02/18/2025 12:56:43 PM

Document Has Been Signed on 02/18/2025 12:56 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:
02/18/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Latonya King, Assistance AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:06 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Assistant Administrator Latonya King who allowed entry of the facility and LPA explained the reason of 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 (9) tool domains were observed and reviewed:, Operational Requirements, Staffing, Personal Records-Training, Client Rights/Information, Client Records/Incident Reports, Health Related Services, Incidental Medical Services, Disaster Preparedness and Emergency Intervention.

1. 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 12/1/2024. The facility has a covered patio with table and chairs for clients to utilized for outdoor activity. The facility would also allow clients to attend community activities if there's an opportunity or if client wanted.

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

3. 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 four (4) 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 Assistant Administrator is Latonya King, and her administrator certification will be expired on 09/26/2026 and she has the required HIV and TB training certificate on file. (continued on 809D)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: 02/18/2025
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(continued from 809)

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

5. 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.

6. 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 have 30 days’ supply of medication. The facility also provides transportation to client's medical and dental appointment.



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

8 Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC 610D) in place, but it needs updating. The facility conducts fire and disaster drill every month. The last fire/disaster drill was conducted on 12/1/2024. The facility has two alternative shelter locations. The staff area also trained annually for the emergency disaster preparedness.

9. 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. Technical advisories provided.

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: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
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