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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606747
Report Date: 08/11/2024
Date Signed: 08/14/2024 02:25:16 PM


Document Has Been Signed on 08/14/2024 02:25 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:SAN DIMAS ADVENTIST HOME CAREFACILITY NUMBER:
197606747
ADMINISTRATOR:JASAIEL DE LEONFACILITY TYPE:
740
ADDRESS:1136 N. SAN DIMAS AVENUETELEPHONE:
(909) 971-9769
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 4DATE:
08/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Administrator Jasaiel De Leon TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Planned Activities: LPA Ramirez observed board games and activities for residents.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. No proof of documented fire drill was observed during records review. LPA Ramirez will issue deficiency based on this record review. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.



See 809-C
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2024
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 4


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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747
VISIT DATE: 08/11/2024
NARRATIVE
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Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory device in resident bedroom#1 was in disrepair. LPA Ramirez will issue Type B deficiency based on this observation.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Jasaiel De Leon expires 04/03/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than one (1) hospice resident.

Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment were observed. LPA Ramirez did not observe Resident Rights form signed for R1, R2, and R3. R1 was missing complete Identification and Emergency form. LPA Ramirez will issue Type B deficiency.

Four (4) deficiencies were observed today. A copy of this report, 809-D and appeals rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/14/2024 02:25 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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1, R2,and R3 the licensee did not comply with the section cited above in 3 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee will have forms signed 8/19/2024 and send proof via email to LPA Ramirez.
Type B
Section Cited
CCR
87506(b)(9)
Resident Records
(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1's emergency contact info was incomplete, the licensee did not comply with the section cited above in 1 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee will have this form completed by 8/19/2024
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/14/2024 02:25 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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, proof of documentation could not be furnished, the licensee did not comply with the section cited above in 4 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee will conduct drill by 8/19/24 and send proof to LPA Ramirez via email.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, bedroom#1 auditory device was is disrepair, the licensee did not comply with the section cited above in 2 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2024
Plan of Correction
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Licensee repaired during visit. No further action required.
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 VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4