191591883-4-11-2023-28-AS-NGAA-CQSVYC-20230411165055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191591883
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:51:14 PM

Document Has Been Signed on 04/11/2023 04:51 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	TORY CARE HOME		FACILITY NUMBER:	191591883
ADMINISTRATOR:	DANILO RAMOS		FACILITY TYPE:	740
ADDRESS:	2721 TORY ST.		TELEPHONE:	(626) 965-4899
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	5	CENSUS: 3	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Danilo Ramos, Administrator		TIME COMPLETED:	04:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Galarza 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 Administrator Danilo Ramos. There are currently 2 elderly residents 60 years and older and one (1) resident under the age of 59 with an Exception in place.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in entrance. Staff room is designated as COVID-19 isolation room if needed. The facility has submitted a COVID-19 Mitigation Plan. An Infection Control Plan has not been submitted. A Technical Advisory was issued.

Operational Requirements:

A current Plan of Operation was reviewed. Once an Infection Control Plan is completed it shall be added to the plan of operation.
The facility has a Dementia Waiver in place. A Hospice Waiver for one (1) is approved.
A fire clearance for four (4) non-ambulatory and one (1) bedridden resident in room #2 is in place.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expired 2/4/2023. Facility does not have a current policy as required.
Facility handles resident's monies but does not have a current Surety Bond.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: TORY CARE HOME	FACILITY NUMBER: 191591883
	VISIT DATE: 04/11/2023

NARRATIVE

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Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood that is licensed for a total of 5 residents [four (4) non- ambulatory residents and one (1) bedridden in room #2]. It consists of 3 resident bedrooms, 1 live-in staff room, living room, dining room, family room kitchen, 2 bathrooms, backyard shaded patio area, and an attached garage.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has one (1) fully charged fire extinguisher. Cleaning supplies and toxic substances are inaccessible to clients.
Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
The facility has a Fire pull-alarm that was tested during the visit.

Staffing:

A total of three (3) live-in staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificates expires 2/10/2024.
Staff have criminal background clearance and training.
Staff files were reviewed. Proof of staff training, health clearance, Criminal Background Clearance, and 1st Aid/CPR training are current.

Resident Records/Incident Reports:

A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, Individual Program Plan (IPP), Individual 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. The Incident report binder was reviewed.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: TORY CARE HOME	FACILITY NUMBER: 191591883
	VISIT DATE: 04/11/2023

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Planned Activities:

The facility does not have a Resident Council or activity calendar.
Residents attend day program Monday - Friday.
Sufficient space to accommodate both indoor and outdoor activities was observed.

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. Kitchen was clean.
No residents have physician orders for modified diets.
Administrator's insulin medication was stored unlocked in two facility refrigerators.

Incident Medical and Dental:

Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications.
Medical and dental transportation is provided.

Disaster Preparedness:

Emergency and Disaster Plan was reviewed.
Records of resident Appraisal and Needs services plans are part of Emergency training.

Residents with Special Health Needs:

No residents are receiving home health services, hospice care, or have postural support physician orders are on file. No residents have prohibited health conditions.
No bed rails for mobility assistance were observed in resident beds.
Individual Program Plans (IPPs), Individual Service Plans (ISPs) and Appraisals are on file.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Danilo Ramos. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 04:51 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: TORY CARE HOME	FACILITY NUMBER: 191591883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.60(a)

Surety bond requirement of licensees handing residents funds. The director shall require as a condition precedent to the issuance of any license for a residential care facility for the elderly, if the licensee handles or will handle any money of a person within the facility, ....that the applicant for the license file or have on file with the department a bond issued by a surety company This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the facility does not have current Surety Bond insurance; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2023
	Plan of Correction
1 2 3 4	License shall have on file a Surety Bond. Submit 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 04/11/2023 04:51 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: TORY CARE HOME	FACILITY NUMBER: 191591883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that it does not have a current Liability Insurance Certificate; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2023
	Plan of Correction
1 2 3 4	Licensee shall obtain Liability Insurance and submit 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 04/11/2023 04:51 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: TORY CARE HOME	FACILITY NUMBER: 191591883
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that Administrator's diabetes insulin medications were stored unlocked in two refrigerators; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Administrator shall ensure insulin medications are refrigerated in a locked box Submit picture proof by tomorrow.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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