198601637-2-18-2023-28-AS-KRAZ-CP6SL4-20230218125742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601637
Report Date: 02/18/2023
Date Signed: 02/18/2023 12:57:55 PM

Document Has Been Signed on 02/18/2023 12:57 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 HOME FOR THE ELDERLY II, INC.		FACILITY NUMBER:	198601637
ADMINISTRATOR:	DEBORAH DAVIS		FACILITY TYPE:	740
ADDRESS:	2315 NAVARRO DRIVE		TELEPHONE:	(909) 624-1286
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	02/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Administrator Deborah Davis		TIME COMPLETED:	01:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/18/2023 at 9:09 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Administrator Deborah Davis arrived shortly after and assisted in tour. Facility is licensed to residents 60 years old and above. The facility is approved for 1 bedridden and 5 non-ambulatory. The facility may retain 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 9:25 am and was led by S1. The Facility is a single story building in a residential area with four (4) resident bedrooms, two (2) shared resident bathrooms, one (1) staff bedroom, one (1) staff bathroom, kitchen, dining room, living room, den/tv room, front yard, backyard and attached car garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Kitchen sink water temperature was measured at 118.9 degrees F. At 9:50 am, LPA observed a pair of yellow rubber dishwashing gloves hanging in between right kitchen cabinet, which was slightly ajar. S1 slightly pushed down on cabinet latch to release door and LPA observed various disinfectant products, cleaning solutions and dish soap. S1 stated the cabinet door to the left was broken. LPA observed door to open from the bottom. S1 removed disinfectants, cleaning solutions and soap while LPA was present and secured them in laundry room cabinet. Laundry room cabinet was observed to be locked and inaccessible to residents.

· Dining Room/Living room/Den/TV room: Dining room was observed to be clean and contained table and 5 chairs. Living room area has 2 recliners and additional seating for clients and guests. Den/Tv room was observed to be clean and contained plenty of seating.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023

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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Document Has Been Signed on 02/18/2023 12:57 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: ST. DANIEL'S HOME FOR THE ELDERLY II, INC.	FACILITY NUMBER: 198601637
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, At 9:50 am, LPA observed a pair of yellow rubber dishwashing gloves hanging in between right kitchen cabinet, which was slightly ajar. S1 slightly pushed down on cabinet latch to release door and LPA observed various disinfectant products, cleaning solutions and dish soap. S1 stated the cabinet door to the left was broken. LPA observed door to open from the bottom. S1 removed disinfectants, cleaning solutions and soap while LPA was present and secured them in laundry room cabinet. Laundry room cabinet was observed to be locked and inaccesible to residents, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to 6 out of 6 persons in care.
	POC Due Date: 02/19/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will ensure disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Administrator/Licensee will re-train staff and provide proof of training material to LPA by 02/19/2023. Administrator/Licensee will provide LPA proof of staff receiving training within 7 calendar days from 02/19/2023. (Due by 02/26/2023)

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: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023

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 HOME FOR THE ELDERLY II, INC.	FACILITY NUMBER: 198601637
	VISIT DATE: 02/18/2023

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

· Resident Rooms 1 - 4: All contained the required furnishings, linens and were observed to be clean. All rooms except rooms #2 and #4 are shared.

· Bathrooms: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Grab bars were observed near toilet and shower. Water temperature in this bathroom was measured at 105.4 degrees F which is in the required 105 – 120 degrees F. Shared resident bathroom #2 water temperature was measured at 118.9 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower.

· Centrally Stored Medications: LPA’s observed hallway closet located nearventry to be locked and inaccessible to residents.

· Attached Garage: LPA observed extra bedding supplies, cleaning products and hygiene products. Garage was locked and inaccessible to residents.

· Backyard: Clean and free from hazards. Gated pool was observed with a lock. LPA observed plenty of seating and shaded area.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. LPA observed auditory sensors on front door, and sliding door. Administrator certificate was observed for Deborah Davis with an expiration date: 01/15/23 and was renewed and pending.

Deficiency is being cited during visit. One (1) technical violation and two (2) technical advisories were noted. Exit interview was conducted with Administrator Davis and a copy of this report, 809-D, LIC 9102 and appeals rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023

LIC809 (FAS) - (06/04)

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