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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601706
Report Date: 05/20/2024
Date Signed: 05/20/2024 02:06:07 PM


Document Has Been Signed on 05/20/2024 02:06 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:BALDWIN GRACIOUS LIVINGFACILITY NUMBER:
198601706
ADMINISTRATOR:DELFIN M. PEGOLLOFACILITY TYPE:
740
ADDRESS:14218 ROCKENBACH STTELEPHONE:
(626) 206-5040
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:6CENSUS: 5DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator Hermina PegolloTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Hermina Pegollo who assisted with visit.LPA explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 6 non-ambulatory residents of which 1 may be bedridden. Facility approved Hospice waiver for 6.

The facility is a single story structure located in a residential neighborhood. It consists of the following: (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, laundry room, detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked and inaccessible to residents. Smoke / Carbon monoxide detectors were in compliance and operational. There are (3) fire extinguisher located throughout the facility which are fully charged. The common areas (dining room, living room) are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. Medications are centrally stored in a locked cabinet in the kitchen. LPA observed detached garage/ storage room. There is second refrigerator in the garage. Garage/Storage door is locked. The resident bathroom is clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Last emergency/ fire drill was conducted on 03/06/23. LPA reviewed residents files to confirm emergency contact is updated. Residents medications reviewed. Medications documented properly and stored appropriately. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared.

Per California Code of Regulations, Title 22, deficiency was cited.

Exit interview was conducted with Herminia Pegollo. A copy of the report and appeal rights were issued.


SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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 2


Document Has Been Signed on 05/20/2024 02:06 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: BALDWIN GRACIOUS LIVING
FACILITY NUMBER: 198601706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA did not observe any emergency drill was conducted since 03/06/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will ensure the facility shall conduct a drill at least quarterly for each shift. Administrator will conduct a fire/emergency drill and send the copy of the recent drill report to LPA by POC due date.
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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
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