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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608358
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:15:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LA POSADA IN SAN DIMASFACILITY NUMBER:
197608358
ADMINISTRATOR:LUCY PARKERFACILITY TYPE:
740
ADDRESS:1452 GOLDRUSH STREETTELEPHONE:
(909) 599-2273
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Lucy Parker, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with administrator, Lucy Parker and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files.

All 5 resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. All 3 bathrooms were toured. Bathrooms have the required grabs bars and non-skid mat. The hot water was 107 degrees which is within the required 105 - 120 degrees. The bathrooms have sufficient hygiene items and hand washing signs. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area. This area is currently being used for visitation.

LPA reviewed 6 resident files to confirm emergency contact is updated and residents have health screenings and or vaccinations. 2 staff files were reviewed to confirm health screenings, vaccination status and fingerprint clearances. All 6 residents' medication records were reviewed. R1's Triamcinolone Acetonide .1% topical cream, refresh tears, and Hydrochlorothiazide 25 mg were present in the facility, but not on the medication list. R2's B Complex is present in the facility, but not on the medication list. R3's Verapamil 120 mg is on the medication list, but not present in the facility. R4's Vitamin E, Aspirin 81 mg, and B12 3000mcg was present in the facility, but no on the medication list.

The deficiency cited is documented on the attached 809D. A copy of the report and appeal rights were provided to administrator.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA POSADA IN SAN DIMAS
FACILITY NUMBER: 197608358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 4 out of 6 persons medications which poses an immediate health, safety or personal rights risk to persons in care. R1's Triamcinolone Acetonide .1% topical cream, refresh tears, and Hydrochlorothiazide 25 mg were present in the facility, but not on the medication list. R2's B Complex is present in the facility, but not on the medication list. R3's Verapamil 120 mg is on the medication list, but not present in the facility. R4's Vitamin E, Aspirin 81 mg, and B12 3000mcg was present in the facility, but no on the medication list.
POC Due Date: 08/09/2021
Plan of Correction
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Administrator is currently correcting the medication list for medication present in the facility. Administrator will obtain discontinuation orders for medication listed, but not present in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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