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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610118
Report Date: 05/18/2024
Date Signed: 05/18/2024 05:06:02 PM


Document Has Been Signed on 05/18/2024 05:06 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:CASA DE MADERAFACILITY NUMBER:
197610118
ADMINISTRATOR:BROWN, DEWALTFACILITY TYPE:
740
ADDRESS:324 WAPELLO STREETTELEPHONE:
(626) 926-3519
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:10CENSUS: 2DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kristina BrownTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 5/18/24. LPA arrived unannounced and met with Staff, Kristina Brown. The purpose of the visit was explained. The facility is licensed for (10) ambulatory residents, ages 60 and over. There are currently (2) residents residing at the home.

The facility consists of five (5) bedrooms: (3) bedrooms on the main level are for residents, (2) bedrooms upstairs are currently used by the administrator. Each bedroom has a private bathroom. The facility also has a living room, game room, dining room, breakfast nook, sun room, and kitchen. The laundry machines are located in the basement along with extra food supplies. The swimming pool is surrounded by a fence and has a locking mechanism. Food supplies of 2 day perishables and a week of non-perishables are observed. Smoke and carbon monoxide combo detectors are hard-wired. Knives, sharps, and cleaning solutions are locked in the cabinet. Medications are centrally stored and locked in a closet. LPA reviewed both residents' medications and there are no deficiencies found.
LPA reviewed 2 resident files. Resident #1 did not have a physician's report on file. Per the administrator, the resident did not have a physician's report upon admission and is being seen by a new physician. None of the residents have restricted or prohibited health conditions.
LPA reviewed 3 personnel files and all the required documents are observed such as the health screening with TB test results, personnel record, and training hours. Staff have current CPR & First Aid certificates and have background clearance.

A deficiency is issued on the LIC809D. An exit interview was held. A copy of this report along with appeal rights were given to Nicole Brown.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: 323-981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024
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 2


Document Has Been Signed on 05/18/2024 05:06 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: CASA DE MADERA
FACILITY NUMBER: 197610118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 residents did not have a physician's report which poses a potential health and safety risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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The licensee shall submit a current physician's report for Resident #1 to LPA by 5/24/24.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: 323-981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2