<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608358
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:57:39 PM


Document Has Been Signed on 09/12/2023 03:57 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: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: 5DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Lorriane Lopez TIME COMPLETED:
04:06 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Alberto Lopez conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Staff Socorro Shook and explained the purpose of the visit. Administrator Lorraine Lopez arrived a few minutes after and assisted with the visit.

LPA observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Sufficient PPE supplies and has an Infection Control Plan posted by the entrance.
Physical Plant & Environment Safety: The 1-story facility is in good repair. Fire and carbon monoxide detectors are in every room and were operation. Fire extinguisher is located at facility and serviced. The 1-story facility consist of the following: Five Bedrooms, including 1 shared resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, office, and patio/deck area attached garage.
Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility does not have proof of enough liability insurance covering injury to residents and guest. Water temperature measured 90.9 which is not between the 105.0 – 105.3 which is within required range.
Staffing: There appears to be sufficient staffing at the facility. The administrator’s Lorraine Lopez certificate expires 11/13/2023. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of on-going training.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 09/12/2023 03:57 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: LA POSADA IN SAN DIMAS
FACILITY NUMBER: 197608358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Water temperature measured 90.9 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
1
2
3
4
Administrator will adjust water temperature to between 105-120 degrees F and send proof 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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: LA POSADA IN SAN DIMAS
FACILITY NUMBER: 197608358
VISIT DATE: 09/12/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 809


Food Service: Facility has 2 days perishable food and 7 days nonperishable food at time of visit.
Planned Activities: Facility has planned activities and supplies and space for activities.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Resident with Special health needs: Facility does not have any residents with special health needs during the time of visit.

Due to time constraints LPA will return another day to complete the inspection.

During today’s visit, no deficiencies were advisories were provided, exit interview conducted and report provided to Licensee Lorraine Lopez

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3