197608258-5-26-2023-28-AS-BPEA-CS7U63-20230526151739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608258
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:18:16 PM

Document Has Been Signed on 05/26/2023 03:18 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:	LEISURE LIVING OF CLAREMONT		FACILITY NUMBER:	197608258
ADMINISTRATOR:	KATHLEEN GONZALES		FACILITY TYPE:	740
ADDRESS:	1738 FINECROFT DRIVE		TELEPHONE:	(626) 622-7296
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Kathleen Gonzales, Administrator		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with DSP staff Edith Velasquez and explained the purpose of the visit. Asst. Administrator, Annette Genie and Licensee/Administrator Kathleen Gonzales arrived shortly after. There are six (6) residents of which three (3) are in hospice care residing in the home.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Resident Rights/Information, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Residents with HSN.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has minimal COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements:

A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. CCL has approved hospice waiver increase for (3) additional hospice residents for a total of (6) hospice residents on 7/10/2019. Liability Insurance policy (policy # 000937293) in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 7/17/2023. The last fire Drill was conducted on 03/20/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed.

Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for five (5) non ambulatory in Rooms #1, 2, 3, 5 and one (1) bedridden in Room #4. Hospice waiver is approved for six (6) residents. It consists of 5 resident bedrooms, 2 1/2 bathrooms, living room, dining room, breakfast nook, kitchen, backyard, patio area, and an attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has (1) fully charged fire extinguisher located in the dining area. Fire extinguisher was last inspected on 01/01/2023. Cleaning supplies and toxic substances are inaccessible to clients. Hot water temperature readings measured 110.5 deg F in bathroom #1 and 117.5 in bathroom #2 which are within the required 105-120 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LEISURE LIVING OF CLAREMONT	FACILITY NUMBER: 197608258
	VISIT DATE: 05/26/2023

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Staffing: A total of eleven (11) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.

Personnel Records-Training: Administrator certificate expired on 5/18/2023. Administrator submitted payment and requirements for renewal on 2/12/2023. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.

Resident Records-Incident Reports: Six (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Records were reviewed.

Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full/half bed rails were reviewed in residents files. LPA conducted (3) resident interviews.

Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation.

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 and well maintained). One (1) resident has a special soft diet residing at this facility. 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.

Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Administrator/RN administer client suppositories.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.

Per California Code of Regulations, Title 22, deficiency was cited.

Exit interview conducted with Licensee/Administrator Kathleen Gonzales. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2023 03:18 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: LEISURE LIVING OF CLAREMONT	FACILITY NUMBER: 197608258
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in which one (1) medication for (1) resident was marked administered on MAR but the medication has not been removed from the bubble pack. In addition, the prescription label for one (1) medication stored in a bottle for another resident had been altered manually which pose an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 05/29/2023
	Plan of Correction
1 2 3 4	Administrator agreed to submit a plan of correction to avoid making the same mistakes and medication errors in the future. Administrator will submit it to CCL/LPA by POC due 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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