<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191501668
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:06:56 PM


Document Has Been Signed on 05/03/2024 03:06 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:BRITISH HOME IN CALIFORNIA LTD, THEFACILITY NUMBER:
191501668
ADMINISTRATOR:MARLENE RAINENFACILITY TYPE:
741
ADDRESS:647 MANZANITA AVETELEPHONE:
(626) 355-7240
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:41CENSUS: 33DATE:
05/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Rosario Munoz - Executive Director/AdministratorTIME COMPLETED:
03:00 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 Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Executive Director/Administrator Rosario Munoz. The facility is licensed to serve for a capacity of 41 residents (34 Ambulatory and 7 Non-Ambulatory only) ages 60 and above. (2) residents receiving hospice care, (2) bedridden and (2) dementia. LPAs observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are adhering to infection control requirements.


Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Dementia plan has not been added to the Plan of Operation. A Hospice Waiver for 6 is approved.Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 07/30/2024. Surety bond of $5,000.00 is current. The facility was not able to provide LPAs the appropriate fire clearance approved by the city for retaining bedridden and dementia residents.
Physical Plant/Environment Safety: There are 6 different cottages (Lambert, Ramona, Foskett, Shafer, Armstrong, Braemar, and Jameson) and each contains resident rooms, living room, small dining room, kitchen, and a laundry room. The main dining room and kitchen are located at the Armstrong building. LPAs randomly selected 6 resident rooms to inspect. They are clean and have the required furnishings. There are no items obstructing the walkways. LPAs observed that the fireplace in Schafer Cottage was not adequately screened. Housekeeper put up the fireplace screen during the visit. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. LPAs observed cameras in the common areas and audio was accessible in the dining area. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has carbon monoxide detectors in each cottage. A shaded area with chairs is provided to the residents.
*****CONTINUED ON LIC809-C*****
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


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: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668
VISIT DATE: 05/03/2024
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
26
27
28
29
30
31
32
Staffing: A total of 24 staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Administrator certificates expired on 04/06/2024, however, renewal was submitted and proof that it was received on 02/21/2024 was provided to LPAs. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training are current.
Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Needs/Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, medication records, and P & I money records. RCFE complaint poster and Personal rights were observed posted.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted in the dining room and in each cottage. The facility has a Resident Council.
Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. LPAs observed a bottle of bleach in the food pantry.
Incidental Medical and Dental: Medications are centrally stored and locked in the med room located in the Jameson cottage. Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.

There were deficiencies found during today’s inspection. Deficiencies cited on LIC 809-D, technical assistance and technical violation were issued.

An exit interview was conducted, and a copy of this report was provided to Rosario Munoz, Executive Director.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 05/03/2024 03:06 PM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that LPAs observed a bottle of bleach in the food pantry which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit photos that chemicals, cleaning supplies, toxic materials are kept in a separate storage area away from the food supplies. Photos to be sent to CCL/LPA 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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 05/03/2024 03:06 PM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the Administrator did not comply with the section cited above in that Dementia plan has not been added to the Plan of Operation which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/10/2024
Plan of Correction
1
2
3
4
Administrator will submit an updated plan of operation showing that the Dementia plan has been added.
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the Administrator did not comply with the section cited above in that the Administrator was not able to provide LPA the appropriate fire clearance approved by the city for retaining bedridden and dementia residents which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/10/2024
Plan of Correction
1
2
3
4
Administrator will submit a request for fire clearance for bedridden and dementia residents and send a copy to CCL/LPA by POC due date.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 05/03/2024 03:06 PM - 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: BRITISH HOME IN CALIFORNIA LTD, THE
FACILITY NUMBER: 191501668

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review, the Administrator did not comply with the section cited above in that the Administrator has not notified the local fire department of oxygen use in the facility which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/10/2024
Plan of Correction
1
2
3
4
Administrator will send proof that the local fire department has been notified regarding use of oxygen in facility.
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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7