191500609-2-7-2023-28-AS-VMAO-CNTNYE-20230207095235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500609
Report Date: 01/26/2023
Date Signed: 02/07/2023 09:54:10 AM

Document Has Been Signed on 02/07/2023 09:54 AM - 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:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	PRISCILLA GAYTAN		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 151	DATE:	01/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Priscilla Gaytan- Assistant Administrator		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Maldonado conducted an unannounced visit to the facility for the purpose of conducting the annual required inspection. LPA met with Assistant Administrator, Priscilla Gaytan, and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed staff files, residents' files, residents' medications, and observed food supplies. The facility is a two-story building, approved to care for 343 non-ambulatory elderly residents, ages 60 and over. The facility has a memory care unit for dementia residents and has a hospice waiver approved for (30). LPA inspected random resident bedrooms and observed them to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. Each resident bedroom is equipped with a bathroom that consists of a shower, toilet, and wash basin. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. The water temperature was tested and measured at between 107F-112F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. Several fire extinguishers were observed throughout the facility. They had current inspections and were fully charged. All sharps were observed to be locked and inaccessible in the facility commercial kitchen, inaccessible to residents in care. Other cleaning supplies were locked and inaccessible, stored in a cabinet in bathroom# 2 and underneath the kitchen sink. All equipment was operational and in good repair. Additional linens were observed in the garage and in good repair. Each bedroom is equipped with smoke/carbon monoxide detectors- operational at the time of the visit. (15) resident files were reviewed and had updated emergency contact information and health screenings. (7) staff files were reviewed and had Criminal Background Clearances, health screenings. LPA discovered that proof of required annual training and certifications for (7) staff . (15) resident medications were reviewed. They are documented properly and given as prescribed. (Report continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
	VISIT DATE: 01/26/2023

NARRATIVE

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LPA observed Personal Protective Equipment (PPE) supplies at the entrance of the facility- the central entry point for screening clients, staff, and visitors and in the hallway. PPE siganage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. All hand washing stations are fully stocked with liquid soap and paper towels.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited during today's visit.

An exit interview was conducted with Assistant Administrator Priscilla Gaytan and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/07/2023 09:54 AM - It Cannot Be Edited

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: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and records review, the licensee did not comply with the section cited above in 5 of out of 7 staff files missing proof of required annual training certification, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2023
	Plan of Correction
1 2 3 4	Assistant Administrator will provide proof of required annual training certification to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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