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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603289
Report Date: 06/29/2026
Date Signed: 06/29/2026 06:29:08 PM

Document Has Been Signed on 06/29/2026 06:29 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/
DIRECTOR:		JANET DE LUNAFACILITY TYPE:
775
ADDRESS:1532 AMAR ROAD STE BTELEPHONE:
(626) 945-0790
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 75CENSUS: 39DATE:
06/29/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Carmela ValadezTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced case management visit to this facility. The purpose of the visit was to follow up on an incident reports received by Community Care Licensing (CCL) on 06/17/26 and 06/18/26. LPA met with Program Supervisor and explained the reason for the visit. Per incident report dated 06/16/26, S1 was conducting a painting activity in a room with C1 present. During the activity, C1 began hitting S1. Supervisor walked by the activity / music room and observed C1 with their long-sleeve sweater pulled over C1's hands while S1 was holding the sleeves together, restricting C1 movement while continuing the assigned activity. Supervisor informed S1 that this intervention was not permitted and instructed S1 to immediately release C1 engage them in activities and utilize verbal prompts and approved behavioral interventions instead. No further issues were reported following the incident. During the visit, LPA was notified that S1 was placed on suspension pending further investigation. Per incident report dated 06/17/26, C2 became aggressive towards S2. C2 attempted to hit S2. While trying to evade themselves, S2 came out of the room and closed the door keeping participant C2 in the room along with two other clients who were then closed in by her holding the door shut. Program supervisor was already on the route to assist and informed staff S2 to let go of the door, which S2 did. Program supervisor then assisted S2 in de-escalating C2. In both incidents staff confirmed there were no injuries reported to C1,C2 or S1 and S2 as a result of these incidents. No medical treatment was required, and law enforcement was not contacted. It was determined that in both incidents, staff utilized interventions that restricted participant movement and were not approved behavior intervention techniques. These actions violated participant personal rights and facility requirements regarding safe supervision and appropriate behavioral nterventions.

Exit interview conducted and the copy of this report, appeal rights were provided to Program Supervisor

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/29/2026 06:29 PM - It Cannot Be Edited


Created By: Nune Margaryan On 06/29/2026 at 05:46 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: 06/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2026
Section Cited
CCR
82072(a)(3)

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Personal Rights.(a) Each client shall have personal rights which include, but are not limited to, the following: Clients shall be free from corporal or unusual punishment, humiliation, intimidation, abuse, or other actions of punitive nature.
This requirement is not met as evidenced by:
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Licensee / Program supervisor retraining for all staff on clients personal rights,
shall ensure staff properly to handle clients' behaviors. Proof of training will be email to LPA.


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 Staff inappropriate intervention, physically restrained improperly and locked/blocked client in room , which poses an immediate health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Nune Margaryan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
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