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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603289
Report Date: 03/03/2022
Date Signed: 03/03/2022 01:41:01 PM

Document Has Been Signed on 03/03/2022 01:41 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KAISER BEHAVIORAL CENTER WEST COVINAFACILITY NUMBER:
198603289
ADMINISTRATOR:INIGUEZ, JOANNAFACILITY TYPE:
775
ADDRESS:1532 AMAR ROAD STE BTELEPHONE:
(909) 287-3557
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 75CENSUS: 51DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Joanna Iniguez; Program ManagerTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met Program Manager Joanna Iniguez and explained the reason for the visit. All clients are currently receiving virtual services.

The following was observed/inspected:
  • LPA and Program Manager toured the facility which included: Store Area, Library/De-Escalation Area, Community Room, Fitness Lab, Science & Tech Room, Arts & Crafts Room, De-Escalation Room, Management Offices, Computer Lab, Music Lab, Living Skills Room, Cafeteria, Changing Room, Conference Room, Community Day Program Area, Storage Room, Staff Cafeteria, and Bathrooms. There are no pools or large bodies of water. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 115.2F which is within the required 105F - 120F degrees. Smoke detectors and Carbon Monoxide which are intertwined were observed throughout the facility and were tested and operable during the visit. There are multiple fire extinguishers located throughout the facility which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Cleaning supplies and disinfectants are locked and are inaccessible to clients. First Aid kit was fully stocked with current manual. Staff were observed wearing masks and screening visitors at the time of entry.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Client meals are not prepared at the facility, therefore food supply was not inspected during today's visit.
  • Currently there are no in-person clients attending the Day Program, therefore medications were not reviewed during today's visit.
  • Staff and Client files were not reviewed during today's visit.
  • LPA observed over 30 day PPE supply.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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