197803655-9-26-2023-28-AS-VMAO-CW2V3A-20230926160424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803655
Report Date: 09/26/2023
Date Signed: 09/26/2023 04:04:33 PM

Document Has Been Signed on 09/26/2023 04:04 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:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Leah Ignacio- Licencee/Administrator		TIME COMPLETED:	04:15 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) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA met with Caregiver, Stephanie Mariano and explained the purpose for the visit. Licensee/Administrator, Leah Ignacio, arrived shortly after and assisted with the visit. The facility is licensed to serve (6) non-ambulatory elderly adults, ages 60 and over. The facility is a single-story home, located in a residential area. The home consists of a living room, (3) residents bedrooms, (1) live-in staff room, (1) room designated for licensee with (1) full bathroom inside the room, (1) resident bathroom, a kitchen, pantry, dining room, living room, detached garage, and shaded patio with seating in the backyard. However, per facility sketch in the plan of operations and posted in the home, all (6) bedrooms and (2) bathrooms should be designated for residents. Per licensee, she was unaware a new sketch needed to be provided and approved by the department. The following (12) CARE tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado requested a copy of the resident and staff roster, and conducted a tour of the physical plant with assistance of Caregiver, Stephanie. The following was observed: There is one central entry point for universal entry screening. The facility does not have an Infection Control Plan approved and or in place, but has a previous approved mitigation plan in place. There is sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the licensee's room and in the garage. (2) bathrooms were equipped with a toilet, shower, and wash basin. They had the required grab bars and non-skid mats. The water was tested and measured at 120F, which is in compliance with Title 22 Regulations. (Report Continued on LIC809-C...)*

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
	VISIT DATE: 09/26/2023

NARRATIVE

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All resident rooms were inspected and observed to have the required furniture, bedding, linens, chair, adequate lighting, and closet space. Additional linens were observed in a hallway closet, inspected and in good repair. At 12:25PM, LPA Maldonado observed a kitchen cabinet locked with only a box of bottles of Ensure and a bottle of salsa. Per Stephanie, the cabinet is kept locked because Resident# 4 (R4) eats a lot at night. Per R4’s Physician’s Report and file review, there is no record of the resident having any medical conditions that would require food for the resident to be locked. At 12:33PM, LPA observed the kitchen refrigerator shelves to have disposable underpads, meant for resident use, under food stored on top. Per Stephanie, the freezer, above the refrigerator, is not working properly and is leaking onto the refrigerator. She states the licensee should be purchasing a new one soon. Sufficient supply of perishable and non-perishable foods was observed. Cleaning supplies/toxins were observed locked in the pantry and underneath the kitchen sink, inaccessible to residents in care. At 12:39PM, LPA observed 2 containers holding visible Sharps Waste on top of R2’s chest of drawers, which is shared with R1, in shared room# 1. The physical plant inside was observed clean. All walkways and pathways were observed to be free of obstruction/hazards. At 12:59PM, LPA also observed several roof boards breaking and falling apart in the back side of the home, near the pantry exit and living room exit. Carbon monoxide/smoke detectors were tested and operated properly. (4) Resident files were reviewed and observed to be complete with all required documents. (2) of (4) residents Physician’s Reports indicate they have a diagnosis of dementia, and (1) resident Physician’s Report indicates the resident has a primary diagnosis of a mental health condition that is not dementia, which is prohibited, per Title 22 Regulations. No auditory devices were observed at entrances/exits of the facility, which is a requirement for dementia care.

Due to time constrains, the annual inspection could not be completed LPA Maldonado will return at a later date to complete the inspection, issue citations necessary.

An exit interview was conducted with Licensee/Administrator Leah, and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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