197606540-2-3-2023-28-AS-KRAZ-CNQ3SF-20230203173016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606540
Report Date: 02/03/2023
Date Signed: 02/03/2023 05:30:38 PM

Document Has Been Signed on 02/03/2023 05:30 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:	LA VERNE MANOR		FACILITY NUMBER:	197606540
ADMINISTRATOR:	JOHN MICHAEL TANADA		FACILITY TYPE:	740
ADDRESS:	2555 6TH STREET		TELEPHONE:	(909) 593-4567
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	80	CENSUS: 31	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Administrator John Michael Tanada		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/03/2023 at 1:30pm. LPA was met by John Michael Tanada and explained the purpose of the visit. Facility is licensed to serve 50 Ambulatory and 30 Non-Ambulatory residents (age 60 and above). LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), copy of Liability Insurance and 3 resident Medication Administration Record (MAR). Resident rooms #1 thru #19, Room #24, Room #30, and Room #38 are cleared for non-Ambulatory residents only. Facility is approved for 8 hospice residents.

LPA OBSERVATIONS: Tour was given by Administrator Tanada at 1:45 pm. Kitchen, pantry, laundry room, centrally stored medications room, 4 randomly selected resident rooms (Room# 14, 16, 23, and 27), Shower room # 4, Visitor bathroom, patio area, and TV/Day room were inspected.

· TV/Day Room: Was clean and had sufficient seating for residents and visitors.

· Kitchen/Pantry: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 106.0 degrees F. Signs promoting hand washing and social distancing were observed.

· Dining Room: Dining room area was clean; chairs were spaced out to promote social distancing. Signs promoting social distancing and cough/sneeze etiquette were not observed throughout dining area. LPA will issue Technical Advisory.

· Laundry Room: Was secured an inaccessible to residents. Room was observed to be clean and organized. LPA observed sufficient linen and towels.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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 02/03/2023 05:30 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: LA VERNE MANOR	FACILITY NUMBER: 197606540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, at 2:10 pm LPA observed two 21 oz cans of Comet Bleach powder cleaner on bathroom window of residnet bathrrom #23, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will secure all disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Residents that wish to use cleaning or disinfectants, will be supervised during use and staff will secure products after each use. Administrator Tanada removed products and secured in storage room during visit.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, Resident #1 (R1) MAR indicated on 02/03/2023 at 8pm, R1 consumed 2 Divalprolex 500mg tablets orally at bedtime, resident #2 (R2) MAR indicated on 02/04/2023 at 8am, R2 consumed 1 Pantoprazole Sodi 40mg orally, at 8pm R2 consumed 1 Simvastatini 10 mg orally at bedtime and 1 Amlodipine Besylate 10 mg orally at bedtime, resident #3 (R3) MAR indicated on 02/03/2023 at 8pm, R3 consumed 1 Quetiapine Fumarate 100 mg orally at bedtime, 1 Zolpidem Tartrate 10 mg orally at bedtime, 1 Donepezil HCL 10 mg orally at bedtime, and 1 Gabapentin 100 mg orally at bedtime, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/04/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will retrain staff on how dispense and record medications. Licensee/Administrator will submit training material and staff acknowledgement of training to LPA.

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 Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/03/2023 05:30 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: LA VERNE MANOR	FACILITY NUMBER: 197606540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

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, resident bathroom# 16 toilet to be dirty and contain stains on seat. Base of toilet was observed to contain dirt and grime. Sink was observed to be dirty and contain grime around rim, visitor bathroom sink contained grime and dirt, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/06/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator will clean resident bathroom #16 and visitor bathroom. Licensee/administrator will submit photo proof to LPA.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 02/03/2023

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· Resident Rooms: Resident room #14 was observed to be clean and contained the required furnishings and linens. LPA was unable to measure water temperature in bathroom due to it being occupied by resident. Resident room #16 was observed to contain the required furnishings and linens. At 2:01 pm LPA observed resident bathroom# 16 toilet to be dirty and contain stains on seat. Base of toilet was observed to contain dirt and grime. Sink was observed to be dirty and contain grime around rim. Water temperature was measured at 106.1 degrees F which is in the required 105 – 120 degrees F. No paper towels were observed in bathroom. Resident room #23 was observed to be clean and contained the required furnishings and linens. At 2:10 pm LPA observed two 21 oz cans of Comet Bleach powder cleaner on bathroom window. This poses an immediate health, safety, or personal rights risk to persons in care. Administrator Tanada removed cans of bleach and secured them in storage area. Water temperature in resident bathroom # 23 was measured at 107.4 degrees F which is in the required 105 – 120 degrees F. No paper towels were observed in bathroom. Resident room #27 was observed to be clean and contained the required furnishings and linens. Water temperature in resident bathroom # 27 was measured at 105.6 degrees F which is in the required 105 – 120 degrees F. No paper towels were observed in bathroom.

· Visitor Bathroom: Water temperature in bathroom was measured at 106.5 degrees F which is in the required 105 – 120 degrees F. LPA observed sink to contain grime and dirt.

· Shower Room #4: Was observed to contain a non-slip mat and was observed to be clean.

· Centrally Stored Medications: At 2:20 pm, LPA discovered 3 resident medication administration record (MAR) was initialed by staff when the resident had not yet taken dosage. Resident #1 (R1) MAR indicated on 02/03/2023 at 8pm, R1 consumed 2 Divalprolex 500mg tablets orally at bedtime. This poses an immediate health, safety, or personal rights risk to persons in care. Resident #2 (R2) MAR indicated on 02/04/2023 at 8am, R2 consumed 1 Pantoprazole Sodi 40mgorally, at 8pm R2 consumed 1 Simvastatini 10 mgorally at bedtime and 1 Amlodipine Besylate 10 mg orally at bedtime. This poses an immediate health, safety, or personal rights risk to persons in care. Resident #3 (R3) MAR indicated on 02/03/2023 at 8pm, R3 consumed 1 Quetiapine Fumarate 100 mg orally at bedtime, 1 Zolpidem Tartrate 10 mgorally at bedtime, 1 Donepezil HCL 10 mgorally at bedtime, and 1 Gabapentin 100 mgorally at bedtime. This poses an immediate health, safety, or personal rights risk to persons in care.

Administrator certificate was observed for John Michael Tanada with an expiration date: 09/27/24. Last fire drill was conducted on 01/06/2023

Technical advisories and deficiencies were cited during visit. Exit interview was conducted with Administrator Tanada and a copy of this report, LIC 809D, LIC 9102, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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