198603289-2-10-2023-28-AS-NGAA-CNWV8N-20230210151303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603289
Report Date: 02/10/2023
Date Signed: 02/10/2023 03:13:24 PM

Document Has Been Signed on 02/10/2023 03:13 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 COVINA		FACILITY NUMBER:	198603289
ADMINISTRATOR:	INIGUEZ, JOANNA		FACILITY TYPE:	775
ADDRESS:	1532 AMAR ROAD STE B		TELEPHONE:	(909) 287-3557
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 75		CENSUS: 30	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Robert Reyes, Lead Supervisor		TIME COMPLETED:	03:20 PM

NARRATIVE

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Licensing Program Analysts (LPA) Galarza and Tena Herrera conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA explained the purpose of the visit to Lead Supervisor Robert Reyes. The Day Program is licensed to serve 75 ambulatory, of which 15 may be non-ambulatory developmentally disabled adults ages 18 and over. Presently there are 30 clients attending on-site day programming, and 24 participating in remote programming.

Physical Plant:

Facility is a one story building located in a shopping center. The program consists of: Storefront room, Fitness Lab, Community Outreach Room, Science and Tech Room, Arts and Crafts, 2 relaxation rooms, Music Lab, Computer Lab, Life Skills, Cafeteria, 2 kitchens, changing room, 3 bathrooms, and 2 offices. There is no outdoor patio area. Facility provides transportation services, and is equipped with 6 vans.

Electrical smoke detectors, and sprinklers were observed. Carbon monoxide detector was observed. A pull-switch / fire alarm sounding device was observed in the hallway corridor.

Bathrooms were observed to be operational, clean, and ADA approved to accommodate non-ambulatory persons in wheelchairs.

The last fire emergency drill was conducted on 12/28/2022. The facility's last fire inspection was conducted on 6/6/2021 by West Covina Fire Department.

*Cleaning solutions, disinfectants, detergent, Epoxy hardener/resin, and wax were observed in the kitchen, life skills, computer outreach room, and science and technology rooms.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 COVINA	FACILITY NUMBER: 198603289
	VISIT DATE: 02/10/2023

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Infection Control:

Visitors are screened in the main entrance lobby area. A sign-in sheet, thermometer, and hand sanitizer were observed. Hand sanitizer was observed in common areas and all activity rooms. Clients are encouraged to wear masks during programming.
COVID-19 Infection Control Practices and signs were observed in the main entrance, activity rooms, offices, and public restrooms.
Adequate supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed.
The Changing Room is designated as the COVID-19 isolation room if needed.
An Infection Control Plan is in place and was reviewed.

Medications:

One (1) centrally stored client medication records was reviewed. 30-day supply of medications were observed.

Staff Files:

Criminal Background Clearance was checked.

Liability Insurance & Surety Bond:

Proof of liability insurance was provided. The facility does not handle client's cash.

*NOTE: The Administrator on record is not current. The current Administrator is Vanessa Mejia. Staff stated the Change of Administrator documents were submitted to CCL. However, proof that the documents were submitted was not provided during the visit. A Technical Advisory was issued.

Exit interview was conducted with Lead Supervisor Robert Reyes. A copy of the report was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/10/2023 03:13 PM - It Cannot Be Edited

Created By: Noemi Galarza On 02/10/2023 at 02:38 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KAISER BEHAVIORAL CENTER WEST COVINA	FACILITY NUMBER: 198603289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82087(a)(3)

Buildings and Grounds

(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section above in that cleaning solutions, disinfectants, detergent, Epoxy hardener/resin, and wax were observed in the kitchen, life skills, computer outreach room, and science and technology rooms; the metal storage cabinets were observed with inoperable locks. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2023
	Plan of Correction
1 2 3 4	Facility agreed to submit a written plan of correction, and proof that the dangerous solutions have been placed in a locked location.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Lisa Hicks

LICENSING EVALUATOR NAME:

Noemi Galarza

LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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