197802543-2-27-2024-28-AS-ALOZ-D2V35E-20240227165638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197802543
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:56:45 PM

Document Has Been Signed on 02/27/2024 04:56 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:	ATHERTON BAPTIST HOMES		FACILITY NUMBER:	197802543
ADMINISTRATOR:	ANGELA LEE		FACILITY TYPE:	741
ADDRESS:	214 SOUTH ATLANTIC BLVD.		TELEPHONE:	(626) 289-4178
CITY:	ALHAMBRA	STATE: CA	ZIP CODE:	91801
CAPACITY:	518	CENSUS: 28	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Angela Lee, Administrator		TIME COMPLETED:	04:59 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required annual inspection. LPA met with Administrator Angela Lee, and explained the purpose of the visit. The facility is licensed as a Continuing Care Residential Community (RCFE-CCRC) to serve 518 residents, 60 years and above, of which 259 may be non-ambulatory. The hospice waiver is approved for 10 residents. There are currently 30 Assisted Living residents, 2 residents in the Memory Care unit, 77 residents in Skilled Nursing, and 254 residents in Independent Living.

LPA Lopez toured the community with the Administrator for the Assisted Living and Memory Care units, in addition to some of the common areas of the facility. The facility has a universal screening at the front lobby for staff and visitors. Temperature is taken and documented on the sign in log. LPA observed Coronavirus (COVID-19) signage posted throughout the facility. The Assisted Living unit and Memory Care unit are detached from the main building. The Assisted Living unit consists of 32 individual apartments with their own bathrooms and a shared dining area. The dining room tables are socially distanced. The Memory Care unit consists of 4 bedrooms, one TV room, 1.5 bathroom, living room, dining room, and kitchen. There is an alert system installed at all the doors.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and have an infection Control Plan at facility.

continued...

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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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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: ATHERTON BAPTIST HOMES	FACILITY NUMBER: 197802543
	VISIT DATE: 02/27/2024

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Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 4 residents' medication, and all medication is administered according to doctor’s orders. However, the PRN medications are missing labels.

Food Service: There are sufficient food supplies of 2-day perishable. Seven day non-perishable in storage. The food is properly stored in the refrigerator to avoid cross contamination.

Due to insufficient time, LPA will return another day to complete inspection.

Deficiency cited (see 809D) , copy of report and appeal rights provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2024 04:56 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: ATHERTON BAPTIST HOMES	FACILITY NUMBER: 197802543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. 3 of 4 medication reviewed did not have labels which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/05/2024
	Plan of Correction
1 2 3 4	Licensee will place orders on all PRN medications and send proof to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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