198603576-3-21-2023-28-AS-ALOZ-CQ5V9L-20230321161432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603576
Report Date: 03/21/2023
Date Signed: 03/21/2023 04:14:39 PM

Document Has Been Signed on 03/21/2023 04:14 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 GENKI		FACILITY NUMBER:	198603576
ADMINISTRATOR:	OMIYA, PEARL		FACILITY TYPE:	775
ADDRESS:	1203 W PUENTE AVE		TELEPHONE:	(626) 960-2566
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 15		CENSUS: 0	DATE:	03/21/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:44 AM
MET WITH:	Pearl Omiya		TIME COMPLETED:	04:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) A.Lopez made an announced visit to the facility for the purpose of inspecting the facility for change to non-ambulatory status. LPA Lopez 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.
Applicant completed the change of AMB/NON-AMB status and clearance from the fire department was granted on 03/08/2023

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 bathroom 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 December 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.

(CONTINUED ON 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 GENKI	FACILITY NUMBER: 198603576
	VISIT DATE: 03/21/2023

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All outdoor and indoor passageways are clear of obstructions. 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. Solid waste shall be stored, located, and disposed of in a manner that will not transmit diseases or odors. Outdoor activity is protected from traffic. LPA observed both bathrooms to have 2 stalls with working toilets and wash basins- fully stocked for hand washing with soap and paper towels. The water temperature was measured in both bathrooms and tested within 99.5*F – 105.4, respectively, which 3 of the 4 faucets are not within the required Title 22, California Code of Regulations.

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 inspection was complete and there was one deficiency (see 809D for details)

An exit interview was conducted with applicant and a copy of this report was furnished along with appeal rights. .

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/21/2023 04:14 PM - It Cannot Be Edited

Created By: Alberto Lopez On 03/21/2023 at 03:43 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: 03/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/23/2023 Section Cited CCR 82088(e)(1)	1 2 3 4 5 6 7	82088 (e) (1) Faucets used by clients for personal care shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will adjust water temperature and send LPA proof that the temperature has been corrected by POC date.
	8 9 10 11 12 13 14	LPA Measured 4 faucets and 3 ranged between 98.4 and 99.5*F – degrees which is not within range.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Alberto Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023

LIC809 (FAS) - (06/04)

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