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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:47:46 PM

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:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:75CENSUS: 62DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Business Office Manager / Diana Marquez
Assistant Administrator / Danny Vera		TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Alberto Lopez conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPAs met with Business Office Manager / Diana Marquez and were later joined by the Assistant Administrator / Danny Vera who assisted with the visit. The facility is licensed to serve for a capacity of 75 residents (41 Ambulatory and 34 Non-Ambulatory only) ages 60 and above. Non-ambulatory to be housed on second floor only. No Bedridden allowed. The facility has an approved Hospice Waiver on file for ten (10) Residents. Brookdale Monrovia does not have an approved Dementia Care Plan in their plan of operation and does not accept or care for residents with dementia. During today's visit, LPAs used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The ground floor consists of a dining room, living room/activity room, laundry room, employee break room and a kitchen. The middle floor consists of resident rooms, an outside patio, library, exercise room, beauty shop, medication room and a laundry room. The upper floor consists of resident rooms and a laundry room. The garage is located on the ground floor.

LPA toured a random selection of resident rooms on each floor. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have signal systems located in each room/restroom and facility phones to call the front desk. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility. The facility has central air and heating accommodations.

The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 4
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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
VISIT DATE: 12/09/2021
NARRATIVE
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were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has carbon monoxide detectors in each resident room. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed and no large bodies of water were observed. A shaded area with chairs is provided in the outside patio, located on the middle floor.

Medications are centrally stored in the locked medication room located on the middle floor. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. The first-aid kit is fully stocked w/First-aid Manual.

The following deficiencies were observed during today's visit;
  • The hot water temperature in the rooms listed below were not in compliance with Title 22 Regulations:
At 11:12am, Room #105 kitchen - measured at 124 degrees F. & bathroom - measured at
122.2 degrees F. At 11:19am, Room #131 kitchen - measured at 124.9 degrees F. & bathroom -
measured at 123.1 degrees F. At 11:38am, Room #234 bathroom - measured at 123.1 degrees F.
At 11:45am, Room 208 kitchen - measured at 121.2 degrees F. At 11:52am, Room #218 kitchen -
measured at 98.5 degrees F., bathroom #1 - measured at 97.2 degrees F. & bathroom #2 - measured at
68.1 degrees F.
  • At 12:04pm, LPAs observed the wooden fence located by the east walk way was in disrepair. The fence had broken pieces and was leaning forward (towards the facility).
  • At 11:07am, LPAs observed the wall near the entrance of room #112 was in disrepair. There was a hole on the corner of the wall. At 11:12am, LPAs observed the kitchen top drawer (next to the sink) located in room #105 was in disrepair and would not open or close properly.

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited

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Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by: The hot water temperature in the rooms listed below were not in compliance with Title 22 Regulations: At 11:12am, Room #105 kitchen - measured at 124 degrees F. & bathroom - measured at 122.2 degrees F. At 11:19am, Room #131 kitchen - measured at 124.9 degrees F. & bathroom - measured at 123.1 degrees F. At 11:38am, Room #234 bathroom - measured at 123.1 degrees F. At 11:45am, Room 208 kitchen - measured at 121.2 degrees F. At 11:52am, Room #218 kitchen - measured at 98.5 degrees F., bathroom #1 - measured at 97.2 degrees F. & bathroom #2 - measured at 68.1 degrees F. This poses an immediate health and safety risk to persons in care.
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and #218 (kitchen, bathroom #1 and bathroom #2).

POC must be submitted to CCL by the POC due date.
Type B
12/16/2021
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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At 11:07am, LPAs observed the wall near the entrance of room #112 was in disrepair. There was a hole on the corner of the wall. At 11:12am, LPAs observed the kitchen top drawer (next to the sink) located in room #105 was in disrepair and would not open or close properly.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: BROOKDALE MONROVIA
FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2022
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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At 12:04pm, LPAs observed the wooden fence located by the east walk way was in disrepair. The fence had broken pieces and was leaning forward (towards the facility). This poses a potential health and safety risk to persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4