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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603289
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:58:14 PM

Document Has Been Signed on 03/05/2024 02:58 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:MEJIA, VANESSAFACILITY TYPE:
775
ADDRESS:1532 AMAR ROAD STE BTELEPHONE:
(626) 945-0790
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 75CENSUS: 49DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Vanessa Mejia, ManagerTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Manager Vanessa Mejia and 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, vendored by San Gabriel/Pomona Regional Center. The facility provides transportation services, and is equipped with 8 vans. Clients bring their own meals and snacks. Facility operates on-site day programming as well as community based programming. Twelve (12) Adult CARE tool domains were utilized with the inspection.

Infection Control:

  • The facility has an Infection Control Plan and COVID-19 Mitigation Plan. Infection control practices and Personal Protective Equipment (PPEs) were observed. Clients and visitors are no longer being screened, but the facility encourages hand washing and self symptom check of staff and visitors.
Physical Plant/Environmental Safety:
  • 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 ADA bathrooms, and 2 offices. There is no outdoor patio area.

  • The main entry door is locked and LPA waited approximately 10 minutes outside until staff answered the phone call to be let in. A technical advisory note was issued.

  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. There is a carbon monoxide detector, and electrical smoke and sprinklers. The facility has three (3) fully charged fire extinguishers. Cleaning supplies and toxic substances are inaccessible to clients. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building has central air conditioning and heating. First aid kits/Manuals are kept in the management office area, consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 03/05/2024
NARRATIVE
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Operational Requirements:
  • The Program Design is current.
  • Fire clearance has been approved for 75 ambulatory and 15 non-ambulatory clients. The facility's last fire inspection was conducted on 1/9/2024 by the West Covina Fire Department.
  • Care and supervision to meet the clients needs was observed.
  • The facility does not handle client's monies and does not have a Surety Bond.

Staffing:
  • A total of 24 staff members provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Six (6) staff files were reviewed for criminal background clearance and training.
  • Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Staff training is conducted monthly.

Client Rights/Information:
  • Personal rights were observed in client files.

Client Records/Incident Reports:
  • Eight (8) client files were reviewed and were observed to be complete. They contained ISP, IPP, medical assessments, and TB clearance.

Food Service:
  • There is a staff kitchen and a client kitchen that were observed to be clean and sanitary. All sharps were locked. Clients bring their own lunch, but snacks and meals are provided if needed. The life skills room had dirty floors, counters, and a refrigerator that is missing a handle. A citation was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
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: 03/05/2024
NARRATIVE
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Health Related Services:
  • The facility has centrally stored medications for one (1) client.

Incident Medical and Dental:
  • All clients have Individual Services Plans on file. However, clients (C1-C6) have IPP reports that are not current, with dates of 2020 & 2021. A citation was issued.
  • Staff training was observed.

Disaster Preparedness, and Emergency Intervention:
  • The facility has an updated Emergency Disaster Plan LIC 610D containing emergency evacuation information.
  • An emergency drill was conducted on 1/15/2024, within the last 6 months as required.


Emergency Intervention:
  • No manual restraints or seclusion are used with clients in care. There is a de-escalation area used by clients.

Deficiencies were cited. See LIC9099D pages.

Exit interview conducted with Manager Vanessa Mejia. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/05/2024 02:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/05/2024 at 01:46 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the majority of the activity meeting rooms (cafeteria, life skills, science/technology, computer lab) had holes caused by C5's self-injurious behaviors, and the floors/sinks, and general maintenance (dirty walls) of the facility was observed to be in disrepair. The rear exit door bottom sweep is torn and the door doesn't close automatically, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Manager shall submit POC pictures that show the completed wall repairs and areas, an installed door sweep/door mechanism repair, and proof that the facility general maintenance and cleaning has been resolved.
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that clients (C1-C6) have IPP reports that are not current, with dates of 2020 & 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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Manager shall submit copies of current IPP reports for clients (C1-C6).
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: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2024 02:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/05/2024 at 02:30 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019€(2)
Criminal Record Clearance.
Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that staff (S5) was hired on 11/3/2023, and has not been associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2024
Plan of Correction
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Administrator staff shall ensure that all staff are cleared and associated to the facility prior to beginning employment. Management staff contacted corporate office staff and staff (S5) was associated via the Guardian system during today’s visit. *Citation is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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