197609007-9-16-2023-31-AS-BPEA-CVQUKP-20230916153929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609007
Report Date: 09/16/2023
Date Signed: 09/16/2023 03:41:38 PM

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME:	GLENDALE GARDEN CARE HOME		FACILITY NUMBER:	197609007
ADMINISTRATOR:	DEANON, IRENE		FACILITY TYPE:	740
ADDRESS:	405 CHESTER STREET		TELEPHONE:	(818) 640-2912
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY:	6	CENSUS: 6	DATE:	09/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Irene Deanon - Licensee/Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Violeta Necesito (Caregiver) and Jorgen Deleon (Caregiver) and explained the purpose of today's visit. Administrator, Irene Deanon arrived at 10:30am and assisted LPA with the inspection.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

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 was reviewed. Facility has not developed and submitted the infection control plan to CCLD. Administrator agreed to develop and submit the Infection Control Plan to CCL. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Staff are adhering to infection control requirements.

Operational Requirements: Administrator cannot find and provide the plan of operation to LPA for review. Liability Insurance policy (policy # 00105792-3) 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 7/29/2024. There was no proof of Fire and Disaster Drill which was to be conducted on a quarterly basis. 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 to serve 6 non-ambulatory residents ages 60 and over, of which six (6) may be bedridden. Hospice waiver for 6 was approved. Current census is five (5) non ambulatory, one (1) ambulatory, two (2) are under hospice care and one (1) is bedridden. Home consists of five (5) resident bedrooms, one (1) office room, three (3) bathrooms, living room, dining room, staff lounge area, kitchen, backyard, and a detached 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 two (2) fire extinguishers which were last inspected on 5/04/2023. Cleaning supplies and toxic substances are inaccessible to residents. At 10:05am, hot water temperature readings measured 113.9 deg F in bathroom #1, 114.9 deg F in bathroom #2 and 116.4 in bathroom #3 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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

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 7

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(8)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the Administrator did not comply with the section cited above in that the first aid kit has missing items like thermometer, tweezers, manual, adhesive tape, etc. Additionally, the kit contained expired BENDARYL itch stopping cream and NEOSPORIN antibiotic pain relieving cream, both creams expired on 05/2021 which poses an immediate health, safety or personal rights risk toresidents in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator shall purchase a First Aid kit with current Manual and submit picture proof to CCL/LPA by POC due date.

Type A

Section Cited

CCR

87465(c)(2)

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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in which LPA reviewed two (2) of the residents (R1 & R2) medications and observed that Pravastatin Sodium (10mg) and Citalopram HBR (10mg) were prescribed to be given in the AM, but Administrator & staff administer them in the PM which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator will call the residents physicians to confirm the correct time to administer medications and contact the Pharmacy to update the physician's orders regarding the medications. Administrator will submit proof to CCL/LPA by POC due date.

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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2023

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 Administrator did not comply with the section cited above in which one of the medications for R2 was administered but the staff did not properly document the MAR and did not indicate that the medication has been given which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator shall conduct in service training to all staff on how to properly dispense and record the residents medications. Administrator will submit a copy of the in service training signed and dated by staff members to CCL/LPA by POC due date.

Type A

Section Cited

CCR

87618(b)(3)(A)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in which Administrator stated that she has not written a report to the local fire department regarding oxygen use in the facility which poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 09/18/2023
	Plan of Correction
1 2 3 4	Administrator agreed to contact the local fire department and make a written report regarding oxygen use in the facility. Administrator will submit proof of correction to CCL/LPA by POC due date.

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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in which the facility has not developed and submitted the infection control plan to CCLD which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator agreed to develop and submit the required infection control plan to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the Administrator did not comply with the section cited above in which the Administrator cannot find and provide the plan of operation to LPA for review which poses/posed a potential health, safety or personal rights risk to residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that the plan of operation is filed in the facility and will submit a copy to CCL/LPA by POC due date.

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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)

Other Provisions

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator cannot provide LPA a copy of the Emergency and Disaster plan for review which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator agreed to update the Emergency and Disaster plan and submit a copy to CCL/LPA by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator cannot provide proof that fire and disaster drill has been conducted in the facility which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that fire and emergency drill is conducted on a quarterly basis. Administrator agreed to conduct a fire and emergency drill to staff and residents as soon as possible and submit proof of in service training, signed and dated by staff members to CCL/LPA by POC due date.

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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 09/16/2023 03:41 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
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(5)

Oxygen Administration - Gas and Liquid

(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the Administrator stated that staff have not received training regarding operation of the oxygen equipment which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that staff have knowledge and ability in the operation of the oxygen equipment. Administrator will scheudle training for all staff members in the operation of the oxygen equipment. Administrator will submit proof of correction to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87705(c)(7)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the Administrator did not comply with the section cited above in which the Administrator did not have planned activities in place for residents which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator will ensure that activities address the needs and limitations of resident with dementia and shall develop planned activities for residents and submit proof to CCL/LPA by POC due date.

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: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: GLENDALE GARDEN CARE HOME	FACILITY NUMBER: 197609007
	VISIT DATE: 09/16/2023

NARRATIVE

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Staffing: A total of eight (8) 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 6/11/2023. However, Administrator stated that she submitted her renewal in May 2023 and finished all the required courses. Administrator awaits for the actual Administrator certificate. 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: Three (3) 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 Notes/Records were reviewed.

Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails were reviewed in five (5) residents files.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. However, Administrator did not have planned activities in place or posted in the facility. Administrator did not have planned activities in place for residents in facility.

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, labeled and well maintained). 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: Five (5) residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel service four (4) residents in the facility. Residents medication are centrally stored in a locked cabinet in the kitchen area. The first aid kit has missing items like thermometer, tweezers, manual, adhesive tape, etc. Additionally, the kit contained expired BENDARYL itch stopping cream and NEOSPORIN antibiotic pain relieving cream, both creams expired on 05/2021. LPA reviewed two (2) of the residents (R1 & R2) medications and observed that Pravastatin Sodium (10mg) and Citalopram HBR (10mg) were prescribed to be given in the AM, but Administrator & staff administer the medicaitons in the PM. Additionally, one of the medications for R2 was administered but the staff did not properly document the MAR and did not indicate that the medication has been administered.

Disaster Preparedness: The facility has not conducted an emergency drill on a quarterly basis for all staff and residents. Administrator cannot provide LPA a copy of the Emergency and Disaster plan for review.

Residents with Special Health Needs: Administrator has not made a report in writing to the local fire department that oxygen is in use at the facility and facility has bedridden residents. Administrator stated that staff have not received training regarding operation of the oxygen equipment.

Pursuant to Title 22, deficiencies were cited on the attached 809D.

Exit interview conducted, appeal rights provided, and copy of report were provided to the Licensee/Administrator, Irene Deanon.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: 323-981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

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