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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603576
Report Date: 11/06/2023
Date Signed: 11/06/2023 01:06:16 PM

Document Has Been Signed on 11/06/2023 01:06 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: 1DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Omiya PearlTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA)Nune Margaryan conducted an unannounced annual visit at the facility using the CARE tool. LPA met Omiya Pearl with and explained the reason for the visit.
The facility is licensed as an Adult Day Program to serve 15 clients of the age 55 years and over which may be non-ambulatory. At the time of visit there was one client at the facility.
The facility is located in a community center building. The program is held in the classroom which consists of a seating area with the tables for meals/activities, resting / TV area, a computer station, a separate activity room to accommodate activities that require more space, a separate bathrooms located inside the main building for client use, and a commercial kitchen available for all programs use. 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 6/5/2023 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 clients and staff files are stored in the locked cabinet in the TV seating area. 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.

Cont. 809C







SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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Document Has Been Signed on 11/06/2023 01:06 PM - It Cannot Be Edited


Created By: Nune Margaryan On 11/06/2023 at 11:17 AM
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: ESGVJCC CLUB GENKI
FACILITY NUMBER: 198603576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087(a)
82087 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.
LPA observed the bathroom sink has some plumbing issues: not draining water.

POC Due Date: 11/06/2023
Plan of Correction
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The Licensee contact the plumber at the time of visit and Plumber fixed the sink.
No further actions needed.
Type B
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. LPA observed the cleaning solution in the unlocked cabinet in the classroom accessible to the clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Licensee immediately remove the solution and locked in the cabinet.
No further actions needed.
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: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023


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: 11/06/2023
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The water temperature was measured in both bathrooms and tested within 108.6 F - 113.7 F, which is within the required Title 22, California Code of Regulations. There is a locked cabinet near the computer station, right side where cleaning supplies/toxins are centrally stored and locked. During the inspection LPA observed cleaning solution in the unlocked cabinet near the computer station on the left side accessible to the clients. LPA also observed that the sink in one of the bathroom has a plumbing issue and not draining the water. All outdoor and indoor passageways are clear of obstructions. There is no pool or large body of water at the premises. LPA reviewed 2 staff and 1 client files.
During todays inspection 2 deficiencies observed. See 809D for details.

An exit interview was conducted with Omiya Pearl and a copy of the report was provided along with appeal rights. .
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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