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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801279
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:32:12 PM


Document Has Been Signed on 08/23/2024 03:32 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:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 5DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Zenaida Uy, Co-AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 8/23/24 using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with the co-administrator, Zenaida Uy. The purpose of the visit was explained. Administrator, Elna Villaflor, arrived later to assist with the visit. The facility is licensed to serve (6) non-ambulatory residents, ages 60 and over, of which (1) may be bedridden. The bedridden fire clearance is approved for bedroom #1 only. The facility is approved to care for (6) hospice residents.

The facility is a single story home that consists of 4 resident bedrooms, 1 staff bedroom, 2 bathrooms, living room, dining area, a den, kitchen, and attached garage. The outdoor has a shaded area with table and chairs. There are no items obstructing the walkway. The fireplace is adequately screened. Knives, disinfectants, and cleaning solutions are stored in the kitchen and inaccessible to residents. The kitchen area is clean and free of insects/vermin. No swimming pool or bodies of water on the premises. There is a carbon monoxide detector in the hallway and smoke detectors are interconnected. Staff are continuing to clean and disinfect the home. They are using appropriate hand hygiene and wearing gloves while assisting residents. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator. Facility has sufficient space to accommodate indoor and outdoor activities.
LPA reviewed all 5 resident files and they have the required documents. Medications are centrally stored and locked. Facility uses the Medication Administration Record (MAR) log to document medications given and no discrepancies were found. LPA reviewed 3 Staff files. The administrator's (Elna Villaflor) certificate expired on 6/5/24, however, it has been verified the renewal documents were received and is pending review by the Administrator Certification Bureau. Staff have current CPR & First Aid certificates and receiving on-going training. The facility has the adequate amount of liability insurance.

No deficiencies were issued today. LPA provided technical assistance on the Emergency Disaster Plan. An exit interview was held and a copy of this report was given to Z. Uy.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024
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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