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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502342
Report Date: 06/10/2022
Date Signed: 06/10/2022 05:49:26 PM


Document Has Been Signed on 06/10/2022 05:49 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:WESTERN ASSEMBLIES HOMEFACILITY NUMBER:
191502342
ADMINISTRATOR:LYNN HUGHESFACILITY TYPE:
740
ADDRESS:350 BERKELEY AVENUETELEPHONE:
(909) 626-3711
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:36CENSUS: 15DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Administrator, Lynn HughesTIME COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Lynn Hughes and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, residents' medications and records, food supply, and staff records. The facility cares for elderly residents and is approved for 2 hospice residents. There are currently 2 residents on hospice.

Resident bedrooms were randomly chosen for inspection. All rooms are private rooms. Each room has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid materials in the shower. The hot water was between 105.7 - 107.2 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances, walk-in refrigerator and freezer were clean and operating properly. The common areas include the TV/living room, dining room, courtyard. These areas are clean and have the required furniture. Exit doors are free of any obstruction. There is a screening station at the entrance of the facility which has PPEs. Staff document resident temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs.

LPA reviewed 4 resident records to confirm emergency contact is updated. Three staff records were reviewed to confirm health screenings, training and fingerprint clearances. Staff #1 (S1) did not have a have health screening on file. LPA reviewed 4 residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiency observed during the visit is documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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Document Has Been Signed on 06/10/2022 05:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: WESTERN ASSEMBLIES HOME
FACILITY NUMBER: 191502342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 3 records reviewed. which poses a potential health, safety or personal rights risk to persons in care. Staff #1's (S1's) file was reviewed and did not have a health screening on file.
POC Due Date: 06/24/2022
Plan of Correction
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Administrator indicated Staff #1 (S1) recently put in a 2 weeks notice to quit. Facility will submit statement that all staff will have health screenings on file.

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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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