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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502342
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:16:31 PM


Document Has Been Signed on 10/19/2023 01:16 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: 10DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Lynn Hughes- AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with facility Administrator, Lynn Hughes, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, (5) staff files, and conducted interviews with (5) staff and (5) residents. The facility is a single-story building, operating as an Residential Care Facility for the Elderly. It is licensed to serve (36) older adults, ages 60 and over, of which all may be non-ambulatory, and had a hospice waiver approved for (2). Currently, there is (1) resident on hospice.
Five (5) random resident bedrooms were inspected and had the required furniture, storage space, and lighting. Bathrooms were equipped with a toilet and wash basin. Showers rooms were observed to be clean and sanitary, Bathrooms and washrooms had the required grab bars and non-skid mats. The water was tested and measured between 114*F-120*F, which is in compliance. The food supplies was observed and had the required 2-day perishables and 7-day non-perishables, as well as emergency food and water supplies available. Fire extinguishers were observed throughout the premises, with current inspections and were fully charged. Walkways and ramps were observed to be free of debris and obstructions/hazards. Sharps were observed stored in the kitchen, inaccessible to residents in care. Toxins and cleaning supplies were observed stored in the basement and storage rooms, locked and inaccessible to residents in care. Centrally stored medications were also observed stored in the medication room, inaccessible. Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and fxpersonal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed. Smoke/carbon monoxide detectors were observed in each room, tested and operational. Staff and resident files were reviewed for required documentation, and observed to be complete. Resident's medications were reviewed and observed to be documented properly and given as prescribed.
During today's visit, no deficiencies were observed or cited.
An exit interview conducted with Administrator. A copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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 2


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
VISIT DATE: 10/19/2023
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Laundry equipment was observed in good repair and operational during the visit. Sufficient linens, towels, and personal hygiene supplies were available. The facility has an approved mitigation plan on file and a current infection control plan submitted to the department. Sufficient PPE supplies were observed stored in the garage. Smoke/carbon monoxide detectors were observed in each room of the home, tested and operational during the visit. (4) Staff and (4) client files were reviewed for required documentation, and observed to be complete. (4) Client's medications were reviewed and observed to be documented properly and given as prescribed. Facility First Aid Manual and Kit were inspected and had the required items.

During today's visit, no deficiencies were observed or cited.

An exit interview conducted with Administrator. A copy of the report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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