191592503-9-13-2023-28-AS-EIRA-CVGR9C-20230908124919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191592503
Report Date: 09/08/2023
Date Signed: 09/13/2023 11:40:42 AM

Document Has Been Signed on 09/13/2023 11:40 AM - 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:	CASA COLINA TRANSITIONAL LIVING CENTER		FACILITY NUMBER:	191592503
ADMINISTRATOR:	STEPHANIE KAPLAN		FACILITY TYPE:	735
ADDRESS:	250 E. HARRISON		TELEPHONE:	(909) 596-7733
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	42	CENSUS: 41	DATE:	09/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Linda Leyva and Stephanie Kaplan		TIME COMPLETED:	12:30 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 Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with Linda Leyva and Stephanie Kaplan and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: Last Disaster Drill was conducted on 09/06/23. Staff are adhering to operational requirements. Physical Plant & Environment Safety: Carbon monoxide detector was tested and is operable. Fire extinguishers were observed. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured as follows: Room #1: 115.8, Room #8: 113.0, Room #9: 116.0, Room #16: 118.1 and Room #18: 116.2. Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training*: Staff files are maintained at the Human Resources office which is on campus. LPA reviewed staff files for Staff #1 (S-1) and Staff #5 (S-5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CASA COLINA TRANSITIONAL LIVING CENTER	FACILITY NUMBER: 191592503
	VISIT DATE: 09/08/2023

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

Client Rights-Information: Client rights are posted and included in Client files. Per Administrator, there are no clients using postural supports.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #5 (C-5). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Appraisal Needs and Services Plan, House Rules, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and are mostly bubbled packed. LPA reviewed medication for C-1 through C-5. The facility utilizes the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are clients with a restricted health condition plan.

Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610D/9 pages) in place. Additionally, this facility has an Environment of Care (EOC) plan in place.
.
Exit interview, appeals rights and a copy of this report was provided to Rachel Tran

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2