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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600753
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:43:40 PM

Document Has Been Signed on 07/29/2022 02:43 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:CENTER FOR BEHAVIORAL CHANGE IIIFACILITY NUMBER:
198600753
ADMINISTRATOR:PIGGEE, KEVINFACILITY TYPE:
735
ADDRESS:2426 MARCELLATELEPHONE:
(626) 913-9994
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 4CENSUS: 4DATE:
07/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Glauce Vance, TIME COMPLETED:
11:20 AM
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icensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Glauce Vance and explained the purpose of the visit. Administrator Kevin Piggee was explained the purpose of the visit telephonically.The facility is a single story home located in a residential neighborhood. It is licensed for 4 level 4I ambulatory only clients. It consists of 3 client bedrooms, dining room, kitchen, living room, family room, 2 bathrooms, backyard with shaded patio furniture,, and detached 2-car garage. The emergency disaster drill was conducted on 6/3/2022. Administrator certificate expired 7/9/2022. Per Licensee/Administrator the renewal documents were submitted on 7/24/2022.

Observations:
  • COVID-19 Infection Control screening protocols and supplies were observed in the entrance area. LPA was screened. Infection control signs were observed throughout the facility.
  • Each client bedroom is designated as a COVID-19 isolation room if needed.
  • Four (4) centrally stored resident medication records were reviewed. Facility maintains a 30-day supply of medications. Centrally stored medications are kept in a locked cabinet.
  • Clients in care do not wear masks because it is not tolerated due to cognitive impairment.
  • Chemicals/cleaning supplies are stored inaccessible to residents.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Smoke detectors were tested and are operational. Fire extinguisher is fully charged.
  • Sufficient supply of Personal Protective Equipment (PPEs) was observed.
  • Outdoor and indoor passageways and exit doors are free of debris and obstruction.
  • Kitchen knives/sharps were observed locked and inaccessible to clients.


NOTE: Infection Control Plan was due June 30, 2022. It has not been submitted to CCL. A technical advisory was issued. Licensee stated it will be submitted soon.
No deficiencies were issued.
Exit interview was conducted with staff Glauce Vance. A copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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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