197803516-9-19-2023-28-AS-CDCN-CVTSJS-20230919135538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803516
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:55:51 PM

Document Has Been Signed on 09/19/2023 01:55 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:	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:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Angelita Lopez, Staff		TIME COMPLETED:	02:15 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	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection using the CARE tools. LPA arrived unannounced and allowed entry by staff, Angelita Lopez. The purpose of the visit was explained. Administrator, Emelita Alangui, arrived shortly after to assist with the visit. The facility is licensed for 6 residents, ages 60 and over, of which 5 may be non-ambulatory and 1 bedridden. The bedridden fire clearance is approved for bedroom #2. The hospice waiver is approved for 1 resident and the facility has an approved dementia waiver. LPA toured the facility and inspected/observed the following: The facility does not have any bodies of water or pool on site. There are 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen, and attached garage. Facility has operable smoke detectors and a carbon monoxide detector located in the dining area. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility. The facility has a fire place but is covered. Staff are aware of appropriate hand hygiene and use gloves when assisting residents with some activities of daily living. The facility has submitted the Infection Control Plan. The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents residing at the facility which 1 is receiving hospice care. The facility has the sufficient amount for liability insurance covering injury to residents and guests. The administrator's (Emelita Alangui) certificate expired on 9/6/22 but LPA verified that the renewal was received by the department and is still pending. Staff employed are fingerprint cleared and associated to the facility. Staff files are maintained at the facility. LPA reviewed the Administrator and 2 other staff files. LPA observed the CPR and/or First Aid certificates for all 3 personnel had expired. Resident files are maintained at the facility and LPA reviewed all 6 files. The files contained the required documents and persons with dementia have current physician's reports. (Continue on LIC809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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: STONEGATE GUEST HOME	FACILITY NUMBER: 197803516
	VISIT DATE: 09/19/2023

NARRATIVE

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Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The foods are properly stored in the refrigerator.
Medications are centrally stored and in their original containers. LPA reviewed 6 residents' medications and they are being administered as prescribed by the physician. The facility has an Emergency Disaster Plan posted with contact numbers.

A deficiency is issued on the LIC809D and technical notes were given today.
An exit interview and a copy of this report along with appeal rights were provided to Co-Administrator, Eugene Alangui.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2023 01:55 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: STONEGATE GUEST HOME	FACILITY NUMBER: 197803516
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which 3 out of 3 staff files reviewed had expired First Aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	The licensee shall ensure all staff employed have current First Aid training and submit current First Aid certificates for Staff #1, #2, and #3 by 10/6/23.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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