197608268-2-23-2024-28-AS-KRAZ-D2QSAD-20240223124210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608268
Report Date: 02/23/2024
Date Signed: 02/23/2024 12:42:14 PM

Document Has Been Signed on 02/23/2024 12:42 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:	HERITAGE SENIOR HOME CARE		FACILITY NUMBER:	197608268
ADMINISTRATOR:	NINO NAVARRO		FACILITY TYPE:	740
ADDRESS:	820 GLENLEA STREET		TELEPHONE:	(626) 272-1540
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS:	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:			TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1-year Visit on
02/15/2024. LPA was met by Administrators Nino Navarro and Michelle Navarro and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which four (4) may be non-ambulatory and has a hospice waiver approved for five (5). Bedroom #1 is approved for one (1) bedridden resident. Bedrooms# 3,5,6 is approved for non-ambulatory. Bedroom#4 is approved for ambulatory only.

LPA OBSERVATIONS: The facility is a two-story dwelling located on a residential street and consists of five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, dining room, living room, attached garage, front yard, and backyard. LPA Ramirez observed auditory devices on entry of door to be operational, sliding door and exits.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 106.5 degrees F. Kitchen appliances were observed to be clean and in working order.

See 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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: HERITAGE SENIOR HOME CARE	FACILITY NUMBER: 197608268
	VISIT DATE: 02/23/2024

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Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 74-degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1-5: LPA Ramirez inspected five (5) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-3: Water temperature in two (2) resident bathrooms were within 105- 120 degrees F. Bathroom#3 was in sue during visit and LPA Ramirez was unable to inspect. Two (2) out of the three (3) bathrooms were observed to be clean and well stocked.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

Garage: PA Ramirez observed emergency water and extra PPE/linens, and toiletry items in this area. Access to garage was observed to be inaccessible to five (5) out of five (5) residents in care.

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 12/18/23 and 09/08/23. LPA Ramirez observed a First Aid kit in kitchen cabinet.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Nino Navarro with an expiration date of 05/04/2024. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed.

Resident Records: Five (5) resident files were reviewed. Five (5) resident medications were reviewed with Administrator Nino Navarro.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.

No deficiencies were cited during this annual inspection. Exit interview was conducted. A copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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