197606747-10-6-2023-28-AS-ALOZ-CWCVTM-20231006164321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606747
Report Date: 10/06/2023
Date Signed: 10/06/2023 04:43:26 PM

Document Has Been Signed on 10/06/2023 04:43 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 CARE		FACILITY NUMBER:	197606747
ADMINISTRATOR:	JASAIEL DE LEON		FACILITY TYPE:	740
ADDRESS:	1136 N. SAN DIMAS AVENUE		TELEPHONE:	(909) 971-9769
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 2	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Jasaile De Leon		TIME COMPLETED:	04:59 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with DSP David Santiago and Administrator Jasiel Deleon showed up a short time later and assisted with the inspection today. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for Six (6) non- ambulatory residents. Currently there are 6 residents at the facility.

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

1. Infection Control. The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies bit does not an Infection Control Plan.
2. Physical Plant and Environmental. The facility is a single story house and located around the residential neighborhood area. The facility includes living room, dining area, kitchen, four clients bedrooms, two bathrooms, Laundry area and an detached garage. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are in each room and common area, and they are working well. LPA tested the hot water temperature in two bathrooms and kitchen, and they were tested between 112.8 -114.9 degrees F. which is within the Title 22 regulation. All the sharp knives and utensils are locked in the kitchen cabinet. All the cleaning supplies and chemicals are locked in the laundry room. The facility has sufficient personal hygiene products for clients to use. All clients rooms are not completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway is safe and clear of obstructions. There is a broken wooden gate, ramp that needs repair or replacement and debris on one side of home that needs to be addressed.

3. Operational Requirements. The facility maintained a fire clearance approved by the fire department which 4 may be non-ambulatory. Currently All the clients in the facility are non-ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill was conducted on 10/04/23.

(Continue on 809C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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 10/06/2023 04:43 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: 10/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)(12)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview the licensee did not comply with the section cited above. Facility does not have current infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Administrator will complete infection control plan and send it to LPA by POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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: SAN DIMAS ADVENTIST HOME CARE	FACILITY NUMBER: 197606747
	VISIT DATE: 10/06/2023

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4. Staffing: The facility has sufficient staffing, and the night supervision staff did receive planned emergency training.

5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Jasaiel Deleon certificate will be expired on 04/03/2025. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current.

6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours were posted at facility.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents.
10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed 2 residents' medication files and all medications are administered according to Doctor’s orders.
11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Facility needs to update emergency disaster plan.
12. Residents with Special Health Needs: No residents have prohibited health conditions.

Deficiencies observed during today’s visit. See (809D) An exit interview was held. A copy of this report, 809D, technical advisory notes, and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC809 (FAS) - (06/04)

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