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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601662
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:43:17 PM


Document Has Been Signed on 12/09/2021 04:43 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:SUNRISE ASSISTED LIVING AT SAN MARINOFACILITY NUMBER:
198601662
ADMINISTRATOR:KIMBERLY SANCHEZFACILITY TYPE:
740
ADDRESS:83332 HUNTINGON DRTELEPHONE:
(626) 292-7800
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:74CENSUS: 49DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Kimberly Sanchez, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Kimberly Sanchez and explained the purpose of the visit. The facility is a 2 story story building licensed for 74 adults 60 and over, approved for 74 non-ambulatory, of which 10 may be bedridden. The facility has a hospice waiver for 12. The facility consists of a Memory Care unit "Reminiscence", 42 rooms, 2 activity rooms, 2 dining rooms, kitchen, 2 tv rooms, library, Bistro room, hair salon, administration offices, laundry rooms, 2nd floor terrace area, and a basement parking lot. The last fire drill was conducted on 11/27/2021, and the last fire alarm system test was on 4/9/2021.
The following were observed/inspected:
  • Entrance screening, sign-in sheet, contact-less thermometer, and hand sanitizer in the main entrance is in place. COVID-19 Infection Control Practices and signs were observed in the entrance area. Common area hallways and 2nd floor public bathrooms have required COVID-19 infection control postings.
  • The interior and exterior physical plant was inspected. Fourteen (14) rooms were inspected. Seven (7) out of 14 rooms did not have hand sanitizer and/or masks in the resident rooms. Discarded furniture was observed in the basement parking lot stalls.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart in activity rooms, and common areas.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • All staff were observed wearing mask. Dementia residents were not observed to be wearing masks. Non-Dementia residents were wearing masks.
  • Six (6) centrally stored resident medication records were reviewed.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Uncovered dessert pies were observed in the freezer and refrigerator.
  • A posted Emergency Disaster Plan was observed.
  • Facility has sufficient supply of Personal Protective Equipment (PPEs).
  • There are evacuation chairs on 1st and 2nd floor stairwells.
  • During a review of the records, LPA reviewed the resident and staff temperature check log, COVID-19 staff training logs, line list of surveillance testing.
***Deficiencies were cited. See LIC 809D. Exit interview was conducted with Administrator Kimberly Sanchez. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
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 12/09/2021 04:43 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: SUNRISE ASSISTED LIVING AT SAN MARINO
FACILITY NUMBER: 198601662

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
HSC
1569.50(a)(3)
Suspension and Revocation
(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that seven (7) out of 14 resident rooms inspected did not have either hand sanitizer, or face masks for the protection against COVID-19 virus; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Administrator agreed to provide staff training on COVID-19 infection control supplies i.e. hand sanitizer and masks in every resident room. Staff shall place masks and hand sanitizer in resident rooms, except in the Memory Care Unit. Submit a written statement stating how the deficiency was corrected by POC due date.
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and kitchen inspection, the licensee did not comply with the section cited above in that LPA observed in the commercial freezer and refrigerator multiple pie desserts left uncovered; which poses an immediate health, safety or personal rights risk to persons in care. Kitchen staff discarded the pies at the time of the visit.
POC Due Date: 12/10/2021
Plan of Correction
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Administrator agreed to provide kitchen staff training on food service cross contamination, and facility protocols. Submit proof of training by POC due date.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/09/2021 04:43 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: SUNRISE ASSISTED LIVING AT SAN MARINO
FACILITY NUMBER: 198601662

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that the basement parking lot had discarded furniture i.e. wheelchairs, walkers, paint cans, tables, chairs, dressers, refrigerators, tables, and lamps; which poses/posed a potential health, safety or personal rights risk to persons in care. At least 4 parking stalls appear to be obstructed with discarded furniture. Administrator stated the parking lot area is temporarily being used to store these items.
POC Due Date: 01/06/2022
Plan of Correction
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Administrator agreed to ensure the parking lot is free of discarded furniture and arrange for pick-up of discarded furniture items.
Submit pictures of the parking lot garage showing that all discarded furniture has been cleared from parking lot stalls.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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