198601637-1-14-2024-28-AS-KRAZ-CZH3A2-20240114170402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601637
Report Date: 01/14/2024
Date Signed: 01/14/2024 05:05:09 PM

Document Has Been Signed on 01/14/2024 05:05 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: 3	DATE:	01/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Administrator Deborah Davis		TIME COMPLETED:	04:15 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 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: 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 112.3 degrees F.

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.

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.

See 809-C

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 HOME FOR THE ELDERLY II, INC.	FACILITY NUMBER: 198601637
	VISIT DATE: 01/14/2024

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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 112.3 degrees F which is in the required 105 – 120 degrees F. Shared resident bathroom #2 water temperature was measured at 106 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 near entry 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 of 01/15/2025.

No deficiencies are being cited. 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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