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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:04:38 PM


Document Has Been Signed on 03/28/2022 04:04 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:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR:YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Fresmida Vizcarra - CaregiverTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Luis Mora, Mary Flores and Investigator Tiffany Brunelli from Investigation Bureau (IB) conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Caregiver Fresmida Vizcarra and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents age 60 and above. Facility has a dementia waiver and are allowed to care for 1 resident on hospice at any one time. The facility is located in a residential area. A tour of the single-story facility included: administrator office room, kitchen, living room, family room, dining room, 6 resident rooms, caregiver room, 3 resident bathrooms, 1 staff bathroom, attached garage, front yard and backyard.

LPA and Fresmida Vizcarra toured the facility and the following was observed: The front and backyard are well maintained. There is a pool in the backyard surrounded with a locked fence. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the all 3 of the residents’ bathroom and measured at 109.4, 110.5, 105.6 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen in a closet located in the family room. There are extra clean towels in each bathroom. There are extra hygiene products in a hallway closet. Two bottles of Lysol spray, a Clorox wipe container, and a bottle of hydrogen peroxide were observed with the hygiene products in the closet which is not locked. Smoke detectors were observed in each room and throughout the facility and are properly operating. There are 2 carbon monoxides in each hallway and are properly operating. There is 1 fire extinguisher located in the kitchen which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. (CONTINUED TO LIC 809C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680
VISIT DATE: 03/28/2022
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Sharps are kept locked in a kitchen cabinet and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen and in a refrigerator located in the garage. Cleaning supplies and toxins are kept locked in the garage and are inaccessible to residents. First Aid kit was fully stocked with current manual and it is kept locked in the residents’ medication cabinet in the family room. Residents medication are centrally stored in a locked cabinet in the family room. Residents and staff files are centrally stored in the administrator office room.

LPAs reviewed all 6 of the residents’ medication and files, and 6 staff files. LPA observed 3 out of the 6 resident files did not have a current physician report. LPA observed 1 of the residents did not have a physician written request for the PRN medication and 2 of the residents PRN medication did not have labels on them. LPA observed all 6 of the staff did not have a valid First Aid/CPR certificate in their file.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the administrator office room.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit and a civil penalty was assessed (refer to LIC 809D & LIC 421FC). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/28/2022 04:04 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: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. LPA observed 2 Lysol sprays, Clorox wipes container, and a hydrogen peroxide in an unlocked hallway closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Administrator will ensure that all cleaning and disinfecting supplies are inaccessible to residents at all times, will provided an in-service training to staff, and submit a copy of sign-in sheet to the department by 3/29/2022.
Type A
Section Cited
CCR
87465(e)
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents. R3 and R4 had PRN medications that did not have a label on them and R5 did not have a physician written request for the PRN medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Administrator will obtain a label and written request from the residents physicians and submit the proof to the LPA by 03/29/2022.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/28/2022 04:04 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: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 6 residents. R1, R2, and R3 all have dementia and the physician report in their files are older than 1 year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Administrator will obtain a current physician report for the 3 residents and submit to LPA by 04/18/2022.
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 6 staff. S1 - S6 do not have a valid First Aid/CPR certificate in there file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Administrator will obtain a current First Aid/CPR certificate for the 6 staff and submit to LPA by 04/18/2022.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4