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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 09/26/2023
Date Signed: 09/27/2023 08:18:27 AM


Document Has Been Signed on 09/27/2023 08:18 AM - 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:BROOKDALE MONROVIAFACILITY NUMBER:
197606301
ADMINISTRATOR:BALBIN, RALPHFACILITY TYPE:
740
ADDRESS:201 E FOOTHILL BLVDTELEPHONE:
(626) 301-0204
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:75CENSUS: 57DATE:
09/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Administrator Logan HarrisonTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Jose Villalobos and Ashley Calderon conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Executive Director Logan Harrison. The following 12 (CARE) tool domains were utilized during the inspection:
Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.
Operational Requirements:
  • A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan.
  • The facility does not have a Dementia Waiver in place. A Hospice Waiver for 10 is approved.
  • A fire clearance for 75 residents of which (34) may be non ambulatory; 0 may be bedridden.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place.
Physical Plant/Environment Safety:
  • The facility does not have Dementia residents. Facility is a 3-story building consisting of 65 resident rooms, 2 activity rooms, beauty salon, dining room, laundry room, and a courtyard patio area.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents.
  • On 6/15/23, The sprinkler system, alarms, fire connections, and kitchen hood system were inspected. The facility has fully charged fire extinguishers.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. LPA tested rooms #103 , #106 , #107, #116, #124, #125, #221, #225, #228, and #231.

Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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 2


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: 09/26/2023
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Staffing:
  • A total of 42 staff members provide care and supervision to the clients.
Personnel Records/Staff Training:
  • Administrator on record is not current. Documents are pending.
  • Staff have criminal background clearance and training.
  • Seven (7) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed.
Resident Records/Incident Reports:
  • A total of seven (7) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.
  • RCFE complaint poster and Personal rights were observed posted.
Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • An activity calendar was reviewed
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Physician orders for modified diets are on file.
  • Sanitation practices and kitchen cleanliness was observed.
Incident Medical and Dental:
  • Six (6) centrally stored resident medications were reviewed.
  • Medical and dental transportation is provided.
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
Residents with Special Health Needs:
  • There are currently (5) residents on Hospice and (8) on Home Health
  • No half bed rails for mobility assistance were observed in resident rooms.
  • Individual Service Plans and Appraisals are on file.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, NO deficiencies were cited. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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