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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803516
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:10:13 PM


Document Has Been Signed on 09/20/2022 02:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:STONEGATE GUEST HOMEFACILITY NUMBER:
197803516
ADMINISTRATOR:EMELITA ALANGUIFACILITY TYPE:
740
ADDRESS:1170 CHISOLM TRAIL DR.TELEPHONE:
(909) 861-3856
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 6DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Emelita Alangui, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Angelita Lopez and explained the purpose of the visit. Administrator Emelita Alangui arrived shortly after. There are six (6) elderly residents in the home. Four (4) residents have Dementia and one (1) is receiving hospice services.The facility is a single story home licensed for 5 non-ambulatory and 1 bedridden resident. It consists of 4 resident bedrooms, 1 staff room, 2 bathrooms, dining room, kitchen, living room, outdoor patio, and attached garage. The last fire/emergency drill was conducted on 6/6/2022. Administrator certificate expired 9/6/2022. Documents were mailed in late Aug. 2022.

OBSERVATIONS:
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Smoke and carbon monoxide detectors were tested and operational.
  • COVID-19 Infection Control Practices and signs that promote hand washing, cough/sneeze etiquette, and physical distancing were observed in the entrance, common areas, hallways, bathrooms and client rooms. There is a screening station at the entrance of the facility to screen visitors.
  • If needed a designated COVID-19 isolation room will be in place.
  • A posted Emergency Disaster Plan was observed.
  • Six (6) centrally stored client medication records were reviewed.
  • Staff were observed wearing mask. Residents were not observed wearing masks due to cognitive impairment.
  • The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food.
  • Facility has an adequate 30-day+ supply of Personal Protective Equipment (PPEs).
  • Sharps/knives were unlocked under the kitchen sink. The centrally stored medication cabinet was unlocked. Both cabinets were locked by staff.
  • Staff (1) is not associated. LPA verified with RO. Transfer request is pending processing. Licensee has not created a Guardian account.
Per California Code of Regulations, Title 22, deficiencies were observed. See LIC 809D. Exit interview was conducted with Administrator Tes Sison. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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Document Has Been Signed on 09/20/2022 02:10 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
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: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that at the beginning of the visit the centrally stored medication cabinet located in the kitchen cabinet was unlocked; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator locked the centrally stored cabinet during today's visit.
***Cleared during the visit.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the sharps/knives cabinet under the kitchen sink was unlocked; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee/Administrator locked the under sink cabinet during the visit.
***Cleared during the visit.

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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/20/2022 02:10 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
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: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the last disaster drill was conducted on June 6, 2022; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2022
Plan of Correction
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Administrator shall conduct a disaster drill. Proof of drill training with staff signatures must be submitted by POC due date.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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