197803655-9-11-2021-28-AS-CWOG-C6QRXL-20210910132454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803655
Report Date: 09/10/2021
Date Signed: 09/11/2021 09:49:04 AM

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:	HOME OF PERPETUAL CARE		FACILITY NUMBER:	197803655
ADMINISTRATOR:	LEAH ANGELA IGNACIO		FACILITY TYPE:	740
ADDRESS:	3027 WENWOOD ST.		TELEPHONE:	(909) 392-3482
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 5	DATE:	09/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:38 AM
MET WITH:	Leah Ignacio		TIME COMPLETED:	01:30 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 Analysts (LPA) Christine Wong and Alberto Lopez conducted an annual required visit. LPA's met with staff William Castro and explained the reason for the visit. Shortly after, the administrator Leah Ignacio arrived and assisted with the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and was approved on 07/26/21 The facility is a single story house located in the residential neighborhood. The facility consists of three resident bedrooms, two bathrooms, staff break room, one live in staff room, kitchen, dining area, living room area, linen closet and detached garage. Each resident bedroom has two beds, two drawers, closet, night stand and sufficient lighting. Each bed has all required linen. Bathrooms have the required grabs bars and non-skid mats except bathroom#2, it was missing the grab bars in the shower. In addition, the toilet in the bathroom#2 was not working and it was clogged and waiting to be fixed. The hot water temperature measured at both bathrooms was between 114.6 and 116.1 degrees F. The smoke detectors and carbon monoxide detectors are operational. The food supply both perishable and non- perishable is adequate. Knives are locked and inaccessible. No dangerous weapon and firearm. There is a shaded outside activity space available . Exits and passageways are free of obstructions. LPA's reviewed 5 resident files to confirm emergency contact is updated. LPA's also reviewed two staff files to confirm health screenings and fingerprint clearances. Staff#1 (S1) was missing the health screening. LPA's reviewed 5 residents' medications and all the medications are centrally stored and the records are current. The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to administrator Leah Ignacio.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 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: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA observed there's no grab in the shower of the bathroom#2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2021
	Plan of Correction
1 2 3 4	The administrator will ensure Grab bars shall be maintained for each toilet; bathtub and shower used by residents. LPA will installed the grab bar in the shower of bathroom#2 and send the picture to LPA by POC due date

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, LPA observed the toilet in the bathroom#2 was not working and its clogged which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2021
	Plan of Correction
1 2 3 4	The administrator will ensure the facility shall be clean, safe, sanitary and in good repair at all times. The administrator will fix the toilet in the bathrom#2 and send the receipt to LPA by POC due 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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

Page: 3 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: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Staff#1 (S1) does not have the health screening and chext x ray result in the file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/17/2021
	Plan of Correction
1 2 3 4	The administrator will ensure All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The administrator send S1 health screening report with TB test result to LPA by POC due 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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021

LIC809 (FAS) - (06/04)

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