198601619-1-14-2024-28-AS-KRAZ-CZH2XV-20240114164744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601619
Report Date: 01/14/2024
Date Signed: 01/14/2024 04:48:29 PM

Document Has Been Signed on 01/14/2024 04:48 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:	ST. DANIEL'S ELDERCARE, INC		FACILITY NUMBER:	198601619
ADMINISTRATOR:	DEBORAH DAVIS		FACILITY TYPE:	740
ADDRESS:	1760 BRIDGEPORT AVE		TELEPHONE:	(909) 624-1093
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 5	DATE:	01/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Administrator Deborah Davis		TIME COMPLETED:	01:15 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 01/14/2024. LPA was met by Administrator Deborah Davis and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for six (6) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), and copy of liability insurance.

LPA OBSERVATIONS: Tour began at 10:45 am. The Facility is a single-story building in a residential area with six (6) resident bedrooms, two (2) staff bedrooms, two (2) dining rooms, three (3) full bathrooms, kitchen, family room, TV room area, laundry room and attached three car garage.

Front Yard: Was clean and well maintained. A pool was observed to be inaccessible to residents.

Kitchen/Pantry: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 114.4 degrees F. Signs promoting hand washing and social distancing were observed. Sharps were secured in cabinet to the left of kitchen sink and inaccessible to residents. Cleaning solutions and disinfectants were observed to be locked in cabinet directly under kitchen sink and inaccessible to residents. Pantry contained emergency water supply.

Dining Room/Family Room/TV Room: Dining rooms were observed to be clean and contained tables and chairs. Family room/TV room area had 7 recliners and additional seating for residents and guests. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area.

Linen Closet: Contained plenty of linens, towels, and hygiene products.

Resident Rooms 1 - 6: All contained the required furnishings, linens and were observed to be clean. Rooms were observed to be clean.

Bathrooms: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Grab bars were observed near toilet and shower. Water temperature in this bathroom was measured at 113.1 degrees F which is in the required 105 – 120 degrees F. Shared Bathroom #2 water temperature was measured at 114.1 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower. Private resident bathroom located in resident bedroom #3 was observed to be clean and contained grab bars and non-slip mats in shower.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2024

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: ST. DANIEL'S ELDERCARE, INC	FACILITY NUMBER: 198601619
	VISIT DATE: 01/14/2024

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Centrally Stored Medications: Is located near hallway and was observed to secured and inaccessible to residents. First aid kit was observed and inspected.

Attached Garage: LPA observed PPE supplies and was inaccessible to residents.

Laundry Room: Was inaccessible to residents and laundry detergent was locked in cabinet above washer and dryer.

Administrator certificate was observed for Deborah Davis with an expiration date 01/15/25. Last fire drill was conducted on 11/03/2023. LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Several fire extinguishers were observed in the facility and were fully charged.

No deficiencies were cited during visit. Exit interview was conducted with Administrator Davis and a copy of this report was provided via email due to printer problems.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2024

LIC809 (FAS) - (06/04)

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