191805183-10-2-2023-28-AS-AGOZ-CW8RUA-20231002131938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191805183
Report Date: 10/02/2023
Date Signed: 10/02/2023 01:22:24 PM

Document Has Been Signed on 10/02/2023 01:22 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. JOHN OF KRONSTADT HOME		FACILITY NUMBER:	191805183
ADMINISTRATOR:	LIANA VERTELKINA		FACILITY TYPE:	740
ADDRESS:	655 NO. SERRANO		TELEPHONE:	(323) 466-6467
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90004
CAPACITY:	21	CENSUS: 14	DATE:	10/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Liana Vertelkina		TIME COMPLETED:	01:30 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) Alma Gonzalez conducted the required annual inspection. LPA met with Administrator Liana Vertelkina 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 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility is using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (21) ambulatory residents age 60 and above. Last Fire Drill was conducted 09/16/23. Staff are adhering to operational requirements. 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. (See LIC809C for the continuation of this report)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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 3

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: ST. JOHN OF KRONSTADT HOME	FACILITY NUMBER: 191805183
	VISIT DATE: 10/02/2023

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

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1 (S1) - Staff 2 (S2). Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificate expired 4/05/2023. Administrator stated the renewal documents were submitted to the recertification unit but an Administrator Certificate has not been received yet. Proof of document submittal was provided.

Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents.

Resident Records-Incident Reports: LPA reviewed Resident files for R1 2. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.

Physical Plant & Environment Safety: LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The physical plant tour was conducted with the assistance of Administrator Liana Vertelkina. The physical plant consists of a single story building with 19 resident bedrooms which consist of 18 single and 1 shared room, each bedroom has a sink and toilet. There is a recreation room, Kitchen, Dining hall, laundry room, medication room, 3 storage rooms, 3 baths and 1 shower, Office, Staff restroom, visitor restroom and outside shaded patio. Resident rooms were randomly chosen for inspection and LPA observed that resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and non-skid mats or strips were properly in place. Hygiene supplies are provided. Water temperature was measured and temperature measured 116 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available.

Refer to LIC 809C for the continuation of this report

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ST. JOHN OF KRONSTADT HOME	FACILITY NUMBER: 191805183
	VISIT DATE: 10/02/2023

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

Planned Activities: Calendars and supplies for activities were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply and disaster food supply was also observed. The food is properly stored in the refrigerator(s). 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. Dining room has adequate seating. Posted menu observed.

Health Related Services/Incidental Medical Services: The medications are centrally stored in a room by the office. Medication room is locked and inaccessible to facility residents. Medication was observed to be in bubble packs and/or original containers. LPA reviewed medication for R1-2. The facility uses the Medication Administration Records (MARs) to document medications given to residents. Medications are administered as prescribed by the Physician.

Per Title 22 Regulations, there were no deficiencies observed during visit.

Exit interview and a copy of this report was provided to Administrator Liana Vertelkina.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3