197606301-8-6-2024-28-AS-BPEA-D7VVM7-20240806163306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606301
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:33:22 PM

Document Has Been Signed on 08/06/2024 04:33 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: 67	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Logan Harrison - Executive Director/Administrator		TIME COMPLETED:	04:30 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 (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Executive Director/Administrator Logan Harrison and explained the purposed of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over. There are currently (67) residents residing in the facility, of which (4) are under hospice care and (0) bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. 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, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/12/2024. Liability insurance in the amount of ($2,250,000) per occurrence and ($20,000,000) in total annual aggregate is in place and expires 12/21/2024. Fire and disaster drills were last conducted on 06/12/2024. Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room. Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room. Third floor: (34) resident rooms and Laundry room. 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. Between 10:30am-11:30am, LPA tested hot water temperature in eight (8) random resident rooms (Rooms: #115, #119, #128, #134, #213, #216, #221 and #231) in the 2nd & 3rd floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. ***CONTINUED ON LIC809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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: BROOKDALE MONROVIA	FACILITY NUMBER: 197606301
	VISIT DATE: 08/06/2024

NARRATIVE

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Staffing: A total of (44) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed a total of (6) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. However, (5) out of (6) files reviewed did not have a valid/current First aid/CPR training certificates on file. Administrator stated that first aid/CPR training will be conducted next week.
Personnel Records-Training: Six (6) staff files were reviewed. Proof of staff training, health clearance, and TB test/vaccinations are current. Administrator's certificate is valid and expires on 11/19/2025.
Resident Rights-Information: Resident personal rights, complaint hot line information and visitors policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis.
Food Service: Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided.
Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, and Medication Records.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Four (4) residents are receiving home health services. Four (4) residents receive hospice care. Five (5) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents doors. LPA did not observe bed rails for mobility assistance in residents' beds.

Per California Code of Regulations, Title 22, deficiency was cited. Exit interview conducted and a copy of the report and appeal rights were provided to Logan Harrison, Executive Director/Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/06/2024 04:33 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: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the Administrator did not comply with the section cited above in that (5) out of (6) staff files reviewed did not have a valid/current First aid/CPR training certificates on fil which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff have been provided with first aid training. Administrator scheduled the First aid/CPR training to multiple staff at the facility next week and shall submit the certificates of these (5) staff: S1/Dedearie Villanueva, S2/Tamaria Mcrae, S3/Kathryn Sandoval, S4/Carina Graham and S5/Dylaney Edinger to CCL/LPA by POC due 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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