197606540-2-7-2024-28-AS-EIRA-D28TG2-20240207134226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606540
Report Date: 02/07/2024
Date Signed: 02/07/2024 03:42:46 PM

Document Has Been Signed on 02/07/2024 03:42 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: 41	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	John Micheal Tanada, Administrator		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Annual Required Visit. LPA met with John Michael Tanada and explained the purpose of the visit.

This facility is licensed to serve 50 Ambulatory and 30 Non-Ambulatory residents (age 60 and above). 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 utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility does has an Infection Control Plan in place.

Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. Carbon Monoxide detectors were tested and operable. Fire extinguishers are located throughout the building (last serviced on 10/05/23). Signal system (alert/notification goes to the nurses station) tested and operable in rooms 3,16,29 and 38. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: Room #3 (109.0*), Room #13 (108.0*), Room #16 (106.0*), Room #29 (113.1*) and Room 38 (107.0*). Bathrooms had non-skid surfaces and grab bars.

Staffing: Facility is adhering to staffing requirements.

**Refer to LIC 809C for the continuation of this report.**

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 02/07/2024

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights.

Resident Rights-Information: Resident rights are posted and included in Resident files.
Planned Activities: Activity schedule is posted.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed near the dining room. 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. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Information, Appraisal/Needs and Services Plan, Resident Rights were observed.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Residents with Special Health Needs: Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there is (1) resident utilizing oxygen equipment and there is (1) resident under hospice care.

Health Related Services/Incidental Medical Services: The medications are stored and locked inside the medication room. Medications are administered as prescribed. Medication Administration is documented in a Medication Administration Record (MAR) log.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to John Michael Tanada (Administrator).

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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