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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608358
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:04:22 PM


Document Has Been Signed on 07/25/2024 01:04 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: 6DATE:
07/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Lorraine Lopez - AdministratorTIME COMPLETED:
01:19 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding incidents that were not reported to the Community Care Licensing Department. LPA met with Lorraine Lopez (Administrator) and explained the reason for the visit.

On 11/17/2022, R1 sustained an injury and showed signs of pain. On 11/19/2022, it was discovered that R1 had a fracture hip. Facility did not report this incident to the Community Care Licensing Division (CCLD).

The deficiency cited is documented on the LIC809-D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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Document Has Been Signed on 07/25/2024 01:04 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: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
87211(a)(1)(B)

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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

This requirement has not been met as evidenced by:
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Administrator is to ensure that Title 22 Section 87211 regulations are met at all times. Administrator will submit detailed incident reports of the incidents/events that occured between 11/17/22 and 11/19/2022 to Community Care Licensing Division (CCLD) by 07/26/2024 3:00pm.
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Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility failed to report an incident report regarding R1 injury.
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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: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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