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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191591883
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:46:55 PM


Document Has Been Signed on 04/04/2024 04:46 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 HOMEFACILITY NUMBER:
191591883
ADMINISTRATOR:DANILO RAMOSFACILITY TYPE:
740
ADDRESS:2721 TORY ST.TELEPHONE:
(626) 965-4899
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:5CENSUS: 3DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Danilo Ramos, AdministratorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the 12 full 12 Care Compliance and Regulatory Enforcement (CARE) Tools domains. The purpose of the visit was explained to Licensee/Administrator Danilo Ramos.

Infection Control:

  • Personal Protective Equipment (PPEs) were observed throughout the facility. Visitor sign-in records are no longer being kept when persons visit the facility.The facility has an Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for four (4) residents is approved.
  • A fire clearance for 4 non-ambulatory and (one) 1 bedridden resident is place.
  • 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 4/28/24. A current surety bond is in place because resident monies are handled by licensees.

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. NOTE: Licensee is currently sleeping in bedroom # 3 and staff (3) is sleeping in bedroom #2 in the bed next to resident (R1). Citation was issued.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were not locked. Cleaning supplies and toxic substances were observed unlocked under the kitchen sink. Citations were issued.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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: 04/04/2024
NARRATIVE
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Staffing:
  • A total of 3 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 2/10/2024. Licensee has not completed the required courses as of yet. A citation was issued.
  • Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training were verified.

Resident Records/Incident Reports:
  • A total of three (3) resident files were reviewed. Files contained Physician's Reports, Appraisals/Appraisal Needs/Services Plans, TB clearance, COVID-19 vaccine cards, and Functional Capability Assessment. There are currently no Dementia residents.
  • RCFE complaint poster and Personal rights were observed posted in the living room area.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No residents require modified diets.

Incident Medical and Dental:
  • Three (3) centrally stored resident medications were reviewed, which contained a 30-day supply of medications.
  • Medical and dental transportation is provided by facility staff.

Disaster Preparedness:
  • An updated Emergency and Disaster Plan LIC 610E has not been developed. Citation was issued.
  • The last emergency disaster drill was conducted on 1/20/2024.
  • Residents with Special Health Needs
  • No residents are receiving hospice care. None are enrolled in home health at this time.

Per California Code of Regulations, Title 22, deficiencies were cited.
Exit interview was conducted with Administrator Danilo Ramos. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/04/2024 04:46 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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the cabinet underneath the kitchen sink was unlocked and contained cleaning solutions and disinfectants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator shall submit picture proof that the kitchen sink cabinet has an installed magnetic lock that Licensee said would be purchased so that staff do not forget to lock the cabinet when the key is no readily accessible. POC is due tomorrow.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/04/2024 04:46 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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that bedroom #2 (R1's) bed did not have a fitted sheet and bedroom #3 (R2's) bed was missing a mattress pad, and R3's bed was missing a flat sheet, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Administrator shall submit picture proof evidence that bedroom #2 beds have fitted sheets and bedroom #3 beds have mattress pads and flat sheets.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the emergency disaster plan is not updated to the current LIC 610E form,which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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Administrator agreed to submit an updated LIC 610E Emergency Disaster Plan.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/04/2024 04:46 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: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services.
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed that resident bedroom #2 has two beds, one is used by R1 and the other is used by live-in staff (S3), and bedroom # 3 has no residents but Licensee is sleeping there, which poses a potential health, safety or personal rights risk to persons in care. Pictures were taken.
POC Due Date: 04/18/2024
Plan of Correction
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Submit a written plan of correction and/or an updated Plan of Operation and Facility sketch.
Type B
Section Cited
CCR
87407(d)
Administrator Recertification Requirements
(d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the Administrator certificate expired 2/10/2024 and the licensee has not completed the required hours of training as of today, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Administrator shall submit proof to LPA that the recertification course hours have been completed and that the recertification documents have been submitted to the Recertification Unit in Sacramento.
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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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