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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:26:46 PM


Document Has Been Signed on 02/29/2024 02:26 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, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 5DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Jeffrey Yang - Designated StaffTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Jeffrey Yang 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 conducted a tour with Jeffrey Yang and observed the following:
Facility was observed in good repair indoors and outdoors. Living room/family room/dining room are all clean, and providing sufficient sitting area, and lighting. Medication cabinet was observed locked in the living room, and fireplace was observed covered. Kitchen area is clean, sharps were observed locked in a drawer. Sufficient food supplies were observed of perishables for at least 2 days and non-perishables for at least 7 days. Each resident room (6) were observed clean with sufficient lighting, furniture, and bedding supplies. Bathrooms (3) were observed clean in working condition with grab bars and skid mats in the showers. Water temperature was tested in each bathroom and tested between 106.7-112.8 degrees F., which is within the required 105-120 degrees F. Garage is used to stored cleaning supplies, and laundry area and it is not accessible to the residents. Backyard has shaded sitting area and a 5ft fence pool inaccessible to the residents. Carbon Monoxide/Smoke detectors were observed, tested, and in working condition. Fire extinguishers were observed and last checked on 12/6/23. Ramps, exit doors, and passageways are free of debris and obstructions.
LPA reviewed files and medication for 5 residents and 3 staff. Resident #5(R5) does not have a current physician's report last dated 7/28/22 and no TB clearance on file. Resident #4(R4)'s physician's report notes resident as bedridden. Files for staff #4-5 (S4-S5)were not available for review at the time of the visit, no proof of TB clearance for S4-S5. (CONTINEUD ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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
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: 02/29/2024
NARRATIVE
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S4 is night staff no current First aid training on file. No training records for any staff within the last 12 months. Emergency Disaster plan and Infection Control plan were reviewed no record on when they were last update observed. Last emergency drill was conducted on 8/1/21.

Administrator certificate was submitted for renewal on 8/22 for Jeffrey Yan # 6009748740 exp. date: 12/2/23 pending approval. Change of administrator was discuss and Mrs. Erlinda Yang will not be returning as the administrator. Mr. Yang will submit the requested documents by 3/8/24.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

*Immediate $500 civil penalties have been assess for fire clearance* Fire Department was notified via telephone (message only) of bedridden residents (2) at the facility on 2/28/24.

Exit interview was conducted with Jeffrey Yang and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/29/2024 02:26 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in resident #4 is noted as bedridden in physician's report which poses an immediate health, safety or personal rights risk to persons in care.
*Immediate $500 Civil Penalties were assess*
POC Due Date: 03/01/2024
Plan of Correction
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Administrator will submit to the department documents for hospice exception request for resident #4 by POC due date 3/1/24.
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/29/2024 02:26 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 staff #4 and #5 do not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Administrator will submit to the department a TB clearance for staff #4 and #5 by POC due date 3/14/24.

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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/29/2024 02:26 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 staff #4 does not have current CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Administrator will submit to the department a copy of First Aid/CPR training for staff #4 by POC due date 3/14/23.
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
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Based on observation and record review, the licensee did not comply with the section cited above in files for staff #4 and #5 were not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Administrator will submit to the department a copy of health screening/LIC503, LIC 501, employee rights, and training.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 02/29/2024 02:26 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: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff did not have 20 hours of training within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Administrator will provide 20 hours of training on the topics above for each staff and will submit a copy to the department of sign-in log, duration of training, and topic by POC due date 3/14/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 last emergency drill was conducted on 8/1/21 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Administrator will conduct an emergency drill and submit a copy of log to the department by POC due date 3/7/24.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 6 of 9


Document Has Been Signed on 02/29/2024 02:26 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: 02/29/2024

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 record review, the licensee did not comply with the section cited above in resident #5 does not have a current physician report, last physician report dated: 7/22/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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Administrator will obtain and submit a copy of physician's report for resident #5 by POC due date 3/14/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9