197803516-9-30-2021-28-AS-NGAA-C7CS66-20210930133525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803516
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:35:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	STONEGATE GUEST HOME		FACILITY NUMBER:	197803516
ADMINISTRATOR:	EMELITA ALANGUI		FACILITY TYPE:	740
ADDRESS:	1170 CHISOLM TRAIL DR.		TELEPHONE:	(909) 861-3856
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	09/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Lita Lopez, caregiver		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/30/2021 Licensing Program Analyst (LPA) Nina Galarza conducted a Required Annual visit. LPA met with caregiver, Lita Lopez who allowed entry into the home. A short time later licensee, Emelita Alangui arrived. The facility cares for elderly residents with dementia and is approved to retain 1 resident on hospice. There is currently 1 resident on hospice. The facility is located in a residential area and contains the following: a living room, family room, kitchen, dining room, a common bathroom with a washbasin, toilet and shower/tub, Four (4) resident rooms with double occupancy, resident room #2 is approved for a bedridden resident and contains a bathroom with a wash basin, toiler and shower/tub, staff room, a two car garage not for resident use that contains laundry; washer and dryer and storage, a front yard and a back yard with a shaded area for resident use. The facility was toured. Bedrooms have the required furniture such as bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. There are 2 bathrooms for residents. Bathrooms have the required grab bars in the shower and near the toilet. The bathrooms are clean and have the required hygiene items. The hot water temperature was 118.7 degrees Fahrenheit. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility. There is a carbon monoxide detector in the hallway. The kitchen was inspected. There is sufficient perishable and non-perishable food. The food was also stored properly. Kitchen appliances are clean and are operating properly. The front and backyard are well maintained. There is no pool or other large bodies of water. The facility is required to have auditory devices on exit doors for dementia residents. Sharp items and chemical are secured and inaccessible to residents. Medications were reviewed. CONTINUED 809-C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STONEGATE GUEST HOME	FACILITY NUMBER: 197803516
	VISIT DATE: 09/30/2021

NARRATIVE

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LPA observed the following deficiencies;

R1 prescribed medication, Tumeric 1500 mg, with no prescription label
R1 prescribed medication, Daily Multivitamin, with no prescription label
Bricks, wooden planks, plastic tubing, discarded satellite dish near the side area of the house
A metal bed frame propped against wall on side area of house

Per California Code of Regulations, Title 22, and California Health and Safety Code, citations were issued for deficiencies observed during the visit. REFER 809-D

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STONEGATE GUEST HOME	FACILITY NUMBER: 197803516
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenence and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed Bricks, wooden planks, plastic tubing, discarded satellite dish near the side of the house, a metal bed frame propped against wall on side area of house. Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator removed metal bed frame at time of visit. Administrator will provide picture proof of bricks, wooden planks, plastic tubing, discarded satellite dish removed to LPA Nina Galarza via email by POC date

Type B

Section Cited

CCR

87465(e)

87465 Incidental Medical and Dental Care (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 residents 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	LPA observed R1 medication, Tumeric 1500 mg, with no prescription label, R1 medication, Daily Multivitamin, with no prescription label. Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator will provide picture proof of medication labeled via email to LPA Nina Galarza by POC 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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina Galarza	TELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC809 (FAS) - (06/04)

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