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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603576
Report Date: 10/17/2024
Date Signed: 10/17/2024 04:56:18 PM

Document Has Been Signed on 10/17/2024 04:56 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ESGVJCC CLUB GENKIFACILITY NUMBER:
198603576
ADMINISTRATOR/
DIRECTOR:		OMIYA, PEARLFACILITY TYPE:
775
ADDRESS:1203 W PUENTE AVETELEPHONE:
(626) 960-2566
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 15CENSUS: 4DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Tony Tang, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 10/17/24. LPA met with Program Director, Tony Tang, and explained the purpose of the visit. Administrator, Pearl Omiya, arrived shortly after. The day program is licensed to serve 15 non-ambulatory individuals ages 18 and over.

LPA used the Compliance and Regulatory Enforcement (CARE) tools to conduct the inspection. The following was observed:
The day program is held in one classroom (Room #3) of the Community Center building. The room has tables and chairs set up for activities and lunch/snack. There is also a t.v. area with couches and computer station. There are smoke and carbon monoxide detectors in the room. The program provides activities indoors. The communal bathrooms are outside of the classroom and located inside the building. Cleaning products are locked. There are no items obstructing the walkways. There is an automated external defibrillator located next to the bathrooms. The fire extinguisher was last inspected on 6/18/24. The kitchen where food is prepared was inspected and no toxic substances are stored near the foods. Lunch and snacks are provided to participants while in attendance. The day program conducts disaster drills every 6 months.
LPA reviewed files for 3 staff and 3 participants. The administrator (Pearl Omiya) has the appropriate qualifications. Staff have current CPR/First Aid/AED certification. Per the administrator, staff receive on-going training but are not documented. LPA provided a technical violation on this section. The participants' files have the admission agreement, health screening, consent forms, and personal rights form. LPA issued a deficiency for one participant without a TB test on file.

A deficiency was issued today on the LIC809D page. Exit interview was held and a copy of this report along with appeal rights was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
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 10/17/2024 04:56 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 10/17/2024 at 02:38 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: ESGVJCC CLUB GENKI
FACILITY NUMBER: 198603576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82069(b)(1)
Client Medical Assessments
(b) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

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 for one of the participants which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The administrator shall ensure all participants have TB test results on file. The TB test results for Client #1 shall be submitted to LPA by 10/31/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024


LIC809 (FAS) - (06/04)
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