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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603289
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:35:44 PM

Document Has Been Signed on 02/25/2025 03:35 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:		MEJIA, VANESSAFACILITY TYPE:
775
ADDRESS:1532 AMAR ROAD STE BTELEPHONE:
(626) 945-0790
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 75CENSUS: 44DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Vanessa Mejia, Program ManagerTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Program Manager Vanessa Mejia and explained the reason for the visit.
The Day Program is licensed to serve 75 ambulatory, of which 15 may be non-ambulatory developmentally disabled adults ages 18 and over. All clients in the day program receive services provided by San Gabriel / Pomona Regional Center. At the time of visit there were 44 clients at the facility. The day program is located in a shopping center and consists of: 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 / kitchen , and 3 Bathrooms ( 1 is in changing room). There is no pool or large body of water at the premises. LPA toured the facility, and the following were observed: The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Four (4) fire extinguishers observed at the facility and are fully charged. The bathrooms were observed to be clean and operational. Water temperature readings measured between the required 105 - 120 degrees F. LPA observed that trash bins in the bathrooms and in the changing room have no covers. Food is not prepared at this program and clients bring their own lunch, but snacks and meals are provided if needed. The kitchen a cafeteria were observed to be clean and sanitary. All sharps were locked. 2 boxes Bleach powder were observed under sink cabinet in the kitchen area unlocked and accessible to clients. Facility does administer medication to one client and the medication is locked in the Management Office. The smoke/carbon monoxide detector was observed to be fully operational. The last fire drill was completed in 02/12/25.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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Document Has Been Signed on 02/25/2025 03:35 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/25/2025 at 01:55 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: 02/25/2025

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
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Based on observation the licensee did not comply with the section cited above. 2 boxes Bleach powder were observed under sink cabinet in the kitchen area unlocked and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Bleach powder boxes were locked immediately. No further action needed.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 03:35 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/25/2025 at 01:55 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

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. LPA observed that trash bins in the bathrooms and in the changing room have no covers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2025
Plan of Correction
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Licensee will purchase trash bins with cover and submit photos and receipts via email to LPA, by POC date.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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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: 02/25/2025
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A first aid kit was observed in the facility with the required items and a first aid manual was available.
There are storage cabinets/ lockers for the clients and staff belongings.
LPA reviewed 4 staff files. Staff had criminal background clearance and associated to the facility. Staff also has an updated First Aid and CPR certificates. LPA reviewed 6 Client files. Files are located in the Program Managers office and stored in a locked cabinet. The client files consist of the admission agreement, IPP/Appraisal Needs & Services Plan, and medical assessment with the TB results.

During today’s inspection deficiencies observed. See 809D for details.

Exit interview conducted with Manager Vanessa Mejia. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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