197801279-9-14-2023-28-AS-KRAZ-CVP5RY-20230914201154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801279
Report Date: 09/14/2023
Date Signed: 09/14/2023 08:12:45 PM

Document Has Been Signed on 09/14/2023 08:12 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, THE		FACILITY NUMBER:	197801279
ADMINISTRATOR:	VILLAFLOR, ELNA C.		FACILITY TYPE:	740
ADDRESS:	1809 LEANING PINE DRIVE		TELEPHONE:	(909) 396-4675
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Elna Villaflor		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 09/14/2023. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Elna Villaflor arrived shortly after to assist with visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for five (5) non-ambulatory residents and one (1) bedridden resident.

LPA OBSERVATIONS: Tour began at 9:00 am and was led by Administrator Villaflor. The facility is a single-story building located in a residential neighborhood with four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, den, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 105.9 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/Den: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area. LPA Ramirez observed three (3) out of six (6) residents in care watching television in den area.

Linen Closet: Contained plenty linens, towels, and hygiene products.

See 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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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: LEANING PINE, THE	FACILITY NUMBER: 197801279
	VISIT DATE: 09/14/2023

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Resident Rooms 1 - 4: LPA Ramirez observed four (4) out of the four (4) resident bedrooms to contain the furnishings, lighting however, bedroom #1 mattress belonging to resident#1 (R1), was observed to not contain required linen. LPA Ramirez discussed with Administrator Villaflor as to the reason as to why R1’s mattress did not have required linen and LPA Ramirez will issue Technical Advisory. Due to the best interest of R1’s health and needs, facility staff will not place linen on mattress and provide physician order or updated health care plan. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. Resident rooms appeared to be clean.

Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 106.4 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 was observed to be clean and water temperature was measured at 105.2 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms.

Centrally Stored Medications: LPA observed cabinet located in staff office to be locked and inaccessible to residents in care.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills: Proof of last documented fire drill was conducted 09/02/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan.

Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for two (2) live in staff. LPA Ramirez observed Administrator’s certificate for Elna Villaflor (6017647740) with an expiration date of 06/05/2024.

Resident Files: Six (6) resident files were reviewed. Admissions agreements and resident personal rights were observed in files.

Liability Insurance & Infection Control Plan: LPA Ramires observed current liability insurance and approved infection control plan was already submitted to this department.

No deficiencies are being cited. Exit interview was conducted with Administrator Villaflor and a copy of this report, LIC 9102 and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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