191290719-5-4-2024-31-AS-EDAT-D4XTLY-20240504145019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290719
Report Date: 05/04/2024
Date Signed: 05/04/2024 02:51:00 PM

Document Has Been Signed on 05/04/2024 02:51 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
Lookup Error,
, CA

FACILITY NAME:	MOTHER GERTRUDE HOME		FACILITY NUMBER:	191290719
ADMINISTRATOR:	SR. ELIA CARO		FACILITY TYPE:	740
ADDRESS:	11320 LAUREL CANYON BLVD		TELEPHONE:	(818) 898-1546
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY:	97	CENSUS: 32	DATE:	05/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Sister Elia Caro - Administrator		TIME COMPLETED:	02:49 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/04/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Sister Elia Caro. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (36) non-ambulatory and (61) ambulatory elderly adults 60 years old and above. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (24) resident room suites. Room suites have shared toilet and shower in the unit, public restrooms, staff rooms, administrative offices, a lobby, a chapel, an activity room, a dining area, a kitchen, a laundry, and exterior courtyard. LPA and administrator toured the physical plant. There were no bodies of water on the premises. Selected rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #103, #108, #111, #206, #209, and #212. Rooms and toilets had call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 115.5 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. All commercial appliances were in working condition. (Evaluation Report continues LIC 809C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MOTHER GERTRUDE HOME	FACILITY NUMBER: 191290719
	VISIT DATE: 05/04/2024

NARRATIVE

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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. Disaster and fire drills with all shifts are conducted quarterly, the last being completed on 03/06/24.

A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted.

LPA conducted an audit of resident #1-#5 (R1-R5) service files, and staff #1-#6 (S1-S6) personnel files were in order and complete. Interviews conducted with (4) facility staff and (3) residents.

The facility is current in CCLD annual fees. The facility has a current administrator certificate for Sister Elia Caro #601355874 valid through 03/23/26. The facility has a current liability insurance effective 03/22/24 thru 03/22/2025.

No deficiencies during this visit.

An exit interview conducted with Sister Elia Caro and a copy of the report is provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024

LIC809 (FAS) - (06/04)

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