197603680-3-18-2023-28-AS-MGFS-CQ2UBM-20230318152630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 03/18/2023
Date Signed: 03/18/2023 03:29:11 PM

Document Has Been Signed on 03/18/2023 03:29 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:	HAMPTON GUEST HOME, INC.		FACILITY NUMBER:	197603680
ADMINISTRATOR:	YANG, ERLINDA		FACILITY TYPE:	740
ADDRESS:	3790 HAMPTON RD.		TELEPHONE:	(626) 351-1215
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 5	DATE:	03/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Jeffrey Yang - Assistant Administrator		TIME COMPLETED:	03:30 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(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Jeffrey Yang Assistant Administrator 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 a single-story home, located in a residential area. It consist of; an administrator office room, kitchen, living room, family room, dining room, 6 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, 1 staff bathroom, a detached garage, a front yard and backyard. LPA Flores conducted a tour of the facility with Fresmida Vizcarra Caregiver and observed the following: Facility is in clean and good repair indoors and outdoors. Kitchen is clean, sharps were locked in drawer next to dishwasher. Sufficient food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. (6) Resident's bedrooms were observed with sufficient lighting, furniture, and bedding supplies. (3) Resident's bathrooms were observed in working condition with grab bars, skid mats, and water temperature was tested between 112.7 - 113.7 which is within the required 105-120 degrees F. Dining room, living room, and family room were observed with sufficient sitting area. Smoke/Carbon monoxide detectors were tested and in working condition. Backyard was observed with covered sitting area, a 5ft fence was observed around the pool. Cleaning supplies are maintain in the garage inaccessible to the residents. Complaint poster is posted on kitchen board printed in 8x11 size poster which is not the required 20x26 size. Last emergency drill was conducted on 8/1/21. Per Title 22 drills should be conducted at least quarterly. LPA Flores reviewed medication and files for 5 residents. Resident #4(R4) last physician's report was dated 3/20/19, annual assessment is required. Resident #1(R1) has a request for special diet. Per staff there are no special diets instructions currently being followed. Each resident file reviewed did not have an admission agreement available in the resident's files at the time of the visit. Staff files were reviewed for (5) staff. File for staff #5(S5) was not available at the time of review. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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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Document Has Been Signed on 03/18/2023 03:29 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
GREATER LA AC/SC, 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: 03/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 staff file for S5 was not available at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will ensure files for each staff are updated and available for review for each staff at all times and will submit personnel record, health screening, tb test, residents personal rights, employee rights for S6 to the department by POC due date 3/31/23.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 5 out of 5 staff files review did not have annual training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will provided additional 20 hours of training for each staff listed on LIC 500 in dementia care, postural support, resctrited health conditions, hospice care and will submit a copy of training to the department by POC due date 3/31/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2023 03:29 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
GREATER LA AC/SC, 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: 03/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 5 out of 5 resident files reviewed did not have an admission agreement available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will submit a copy of admission agreement for (5) residents to the department by POC due date 3/31/23.

Type B

Section Cited

CCR

87555(b)(7)

General Food Service Requirements

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 5 residents receives a modified diet as requested by physician which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that R1's special diet needs are met and staff are knowledgeable of the diet needs of resident to ensure preparation of meals is appropiate. Administrator will submit a written acknowledgement of special diet with procedures to ensure special diet needs are met and signed by staff and administrator by POC due date 3/31/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 03/18/2023 03:29 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
GREATER LA AC/SC, 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: 03/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705 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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files review, for R4 last physician's report is dated 3/20/19 on file which poses/posed a potential health, safety or personal rights risk o persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will obtain a current physician report and will submit a copy to the department by POC due date 3/31/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

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

FACILITY NAME: HAMPTON GUEST HOME, INC.	FACILITY NUMBER: 197603680
	VISIT DATE: 03/18/2023

NARRATIVE

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Annual training for staff was not available during the visit. An administrator certificate was reviewed for Jeffrey Yang #6009748740 exp: 12/1/23.

Deficiencies have been noted on 809D per Title 22 Regulations.

Exit interview was conducted with Fresmida Vizcarra Caregiver. Report, and LIC 809D were email for signature due to technical issues. A copy of report, LIC 809D, and appeal rights were email.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2023

LIC809 (FAS) - (06/04)

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