197606301-2-13-2023-28-AS-ALOZ-CNZVU4-20230213154408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 02/13/2023
Date Signed: 02/13/2023 03:44:19 PM

Document Has Been Signed on 02/13/2023 03:44 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:	BROOKDALE MONROVIA		FACILITY NUMBER:	197606301
ADMINISTRATOR:	BALBIN, RALPH		FACILITY TYPE:	740
ADDRESS:	201 E FOOTHILL BLVD		TELEPHONE:	(626) 301-0204
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	75	CENSUS: 54	DATE:	02/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Danny Vera, Executive Director		TIME COMPLETED:	03:51 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Danny Vera, Executive Director and explained the purpose of the visit. The facility is licensed to serve 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, LPA used the infection control domain to complete the Required - 1 Year inspection.

The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· LPA was not screened for this visit.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not have designated isolation room as residents all have private rooms.
· 6 client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· 6 client rooms were equipped with alcohol based hand sanitizer.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.

Deficiencies cited, please see 809D for details

Exit interview conducted with Danny Vera, Executive Director and copy of report and appeal rights provided

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

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 02/13/2023 03:44 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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Room #122 shower facet is loose which poses potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2023
	Plan of Correction
1 2 3 4	Administrator will repair shower facet in room #122 and send proof to LPA by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2023 03:44 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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(1)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) 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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Bathroom in first floor closer to reception desk had water temperature at 120.02 degrees F. Shower water in room 125 measured 98.1 degrees F. Room 234 water measured 121.1 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2023
	Plan of Correction
1 2 3 4	Administrator will adjust water temperature and send proof to LPA by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

LIC809 (FAS) - (06/04)

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