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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607333
Report Date: 07/08/2023
Date Signed: 07/08/2023 04:25:59 PM


Document Has Been Signed on 07/08/2023 04:25 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
Lookup Error,
, CA



FACILITY NAME:GLENDALE GOLDEN YEARS HOMEFACILITY NUMBER:
197607333
ADMINISTRATOR:AURELIO TRILLANAFACILITY TYPE:
740
ADDRESS:1502 LYNGLEN DR.TELEPHONE:
(818) 484-5693
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY:6CENSUS: 6DATE:
07/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Maria TrillanaTIME COMPLETED:
11:24 AM
NARRATIVE
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On 07/08/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Maria Trillana. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory and (2) may be bedridden elderly adults ages 60 and above. The facility is approved for (3) hospice residents. The facility has (2) residents on hospice care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 72 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: GLENDALE GOLDEN YEARS HOME
FACILITY NUMBER: 197607333
VISIT DATE: 07/08/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 01/28/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 09/04/22 through 07/23/23.

An audit of resident #1-#6 (R1-R6) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. Interviews were conducted with (3) residents and (3) staff.

Deficiencies:
  • Staff #2 did not have a LIC 503 Health Screening/TB Test
  • Resident #4 missed prescribed medication on 07/07/23 observed medication still in bubble pack.


Based on observations, interviews, and record reviews, the facility is in violation of California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted with Maria Trillana and a copy of the report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/08/2023 04:26 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
Lookup Error,
, CA


FACILITY NAME: GLENDALE GOLDEN YEARS HOME
FACILITY NUMBER: 197607333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified Resident #4 missed a prescribed medication on 07/07/23. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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The administrator will ensure to review Title 22 Reg 87465 and retrained staff on administration of medications to residents in care. Administrator will send a written plan stating Reg 87465 was reviewed and staff have been retrained. POC must be submitted before due date 07/24/23.
Type B
Section Cited
CCR
87412(a)(11)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (11)A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. LPA identified Staff #2 did not have LIC 503 Health Screening on file and no TB Test. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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The administrator will ensure that all staff must have LIC 503 Health Screening on file including a TB Test due of hire. Administrator will have staff #2 get a TB test completed and POC must be sent by due date: 07/24/23.
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: Janae HammondTELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2023
LIC809 (FAS) - (06/04)
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