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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603576
Report Date: 10/03/2022
Date Signed: 10/03/2022 12:48:26 PM

Document Has Been Signed on 10/03/2022 12:48 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:ESGVJCC CLUB GENKIFACILITY NUMBER:
198603576
ADMINISTRATOR:OMIYA, PEARLFACILITY TYPE:
775
ADDRESS:1203 W PUENTE AVETELEPHONE:
(626) 960-2566
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 15CENSUS: 0DATE:
10/03/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pearl Omiya- ApplicantTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an announced visit to the facility for the purpose of completing the pre-licensing inspection. LPA Maldonado met with applicant Pearl Omiya and explained the purpose for the visit. An application was submitted to CCLD on 04/29/22, for initial license for an Adult Day Program to serve consumers of the age 55 years and over. The requested capacity is for 15 consumers, of which all will be ambulatory only.

The facility where the program will be held is a classroom, located in a community center building. It consists of a table seating area for meals/activities, a TV seating area, a computer station, a separate activity room to accommodate activities that require more space, a separate bathrooms located inside the main building for consumer use, and a commercial kitchen available for all programs use. LPA observed sufficient seating available inside the classroom for the requested capacity. There is a locked cabinet near the computer station where cleaning supplies/toxins and medications will be centrally stored- inaccessible to persons in care. All required signs were posted near the entrance door, including but not limited to: labor laws, complaint procedures, Emergency Disaster Plan, Emergency Exit Plan. LPA observed a fire extinguisher near the TV seating area, in the classroom and in the activity room near the entrance- both had recent inspections and were fully charged. The smoke/carbon monoxide detectors were observed in the classroom and activity room. They were tested and observed to be fully operational- the last fire drill was completed in June 2022 for the community center. A first aid kit was observed in the facility with the required items and a first aid manual was available. All consumer and staff files will be stored in the main office, which is 2 doors down from the classroom where the day program will be held. The restrooms were observed inside the main building- separate bathrooms for consumers to use. LPA observed both bathrooms to have 2 stalls with working toilets and wash basins- fully stocked for handwashing with soap and paper towels. The water temperature was measured in both bathrooms and tested within 105.7*F - 114.8*F, respectively, which is within the required Title 22, California Code of Regulations.
(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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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: ESGVJCC CLUB GENKI
FACILITY NUMBER: 198603576
VISIT DATE: 10/03/2022
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Two mini fridges were observed inside the classroom, to be operational and will be used for consumer snacks, drinks, and any food they may bring that needs to be stored.

A COVID-19 screening station was observed at the entrance of the room and COVID signage was observed throughout the room to promote hand washing, face coverings, and social distancing. Board games were located in a cabinet drawer near the entrance for consumer use and a sample menu and activities schedule also was located at the entrance of the room. Snacks, sufficient non-perishable foods, and water were also observed in the cabinets and on the counter, that will be provided and readily available to persons in care. The commercial kitchen located across the courtyard has a local Department of Public Health permit and will be used in preparing meals for the consumers, for future events.

The Pre-Licensing was complete and no deficiencies were found. LPA Maldonado has cleared the physical plant and Comp III was completed during today's visit with the applicant Pearl Omiya.

An exit interview was conducted with applicant and a copy of this report was furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, she has been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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