197803655-9-13-2022-28-AS-CWOG-CJ8TRQ-20220913145755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803655
Report Date: 09/13/2022
Date Signed: 09/13/2022 02:58:04 PM

Document Has Been Signed on 09/13/2022 02:58 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:	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: 4	DATE:	09/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Leah Ignacio		TIME COMPLETED:	03:30 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 conducted an annual required visit. LPA met with Administrator Leah Ignacio explained the reason for the visit and she also assisted LPA with the annual visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. The facility is a single story house located in the residential neighborhood. The facility consists four resident bedrooms, two bathrooms, live in staff room, kitchen, dining area, living room area, linen closet and a detached garage. All 4 resident bedroom were toured. Bedroom#1 and #2 has one bed, one drawer, one chair, required bed linen and furniture and sufficient lighting and closet space. Bedroom#3 and #4 has two beds, two drawers, required bed linen and furniture and sufficient lighting and closet space. Two bathrooms were toured and they are clean, sanitary and in a good working condition. The bathrooms have required grab bars and non-skid mats. The smoke detectors and carbon monoxide detectors are operational. The food supply both perishable and Non- perishable is adequate. Knives are locked in the pantry and inaccessible to residents. The living room and dining area are clean and have required furniture. No dangerous weapon and firearm. There is a shaded outside activity space available. Exits and passageways are free of obstructions. LPA reviewed 4 resident files to confirm emergency contact is updated. LPA also reviewed one staff file to confirm health screenings and fingerprint clearances. LPA reviewed 4 residents' medications and all the medications are centrally stored and the records are current. See LIC 809C for continuation.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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

Document Has Been Signed on 09/13/2022 02:58 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: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/27/2022 Section Cited	1 2 3 4 5 6 7	87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that ........Postural supports may be used under the following conditions.(3)written order from a physician indicating the need for the postural support shall be maintained in the resident’s record
	8 9 10 11 12 13 14	The requirement is not met as evidenced by LPA was not able to observe the doctor's order for Resident#1(R1)'s half bed rail which posed a potential risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
	VISIT DATE: 09/13/2022

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
26
27
28
29
30
31
32

Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, social distancing, and the disinfecting products are available in each common area and facility is disinfected every night. The bathrooms have sufficient soap, paper towels, and signs, and PPE supplies are sufficient for more than 30 days.

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: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3