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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601706
Report Date: 06/23/2023
Date Signed: 06/23/2023 04:23:35 PM


Document Has Been Signed on 06/23/2023 04:23 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:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Maria Lerma, CaregiverTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Maria Lerma. The purpose of the visit was discussed telephonically with Administrator Herminia Pegolla telephonically. There are currently 5 elderly residents with Dementia 60 years and older residing in the facility. Zero (0) residents are enrolled in hospice or home health at this time.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in log. The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation and Personnel files were reviewed.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 6 is approved.
  • A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 2.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expired 7/1/2023. However, other parts of coverage are current.
  • A surety bond is not applicable.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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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
VISIT DATE: 06/23/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 1 may be bedridden. It consists of a kitchen, living room, dining room, activity room, covered patio area, backyard, laundry room, 3 resident bedrooms, 1 staff room, 2 bathrooms, and detached garage.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water.
  • Cleaning supplies and toxic substances were observed unlocked in the laundry room. The laundry room was not locked. Kitchen knives were unlocked in cabinet and drawers. Citations were issued.
  • The main entrance door auditory alarm was turned off and side door's auditory alarm is not operable.
  • The facility has three (3) fully charged fire extinguisher.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:
  • A total of 3 regular caregiver staff & 4 on-call staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expires 10/16/2023.
  • Personnel files/training were reviewed; with the exception of on-call staff (S2's) file. Staff (S5) does not have a file, but is cleared and associated. Citation was issued.

Resident Records/Incident Reports:
  • A total of five (5) resident files were reviewed; which included admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. Resident (R5) did not have a current Physician Report.
  • RCFE complaint poster and Personal rights were observed posted.


***narrative continues next page***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
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
VISIT DATE: 06/23/2023
NARRATIVE
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Resident Records/Incident Reports:
  • A total of five (5) resident files were reviewed. Files were observed to be incomplete. They were missing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • Indoor and outdoor activities are performed daily.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • No Physician orders for modified diets are on file.
  • Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:
  • Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications. Resident (R1) had medications in their room drawer that were unlocked.
  • Medical and dental transportation is provided by family members and staff.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last emergency disaster drill was completed on 3/6/2023.


See next page
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/23/2023 04:23 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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 resident (R1's) Nystatin medication and incontinence products were observed unlocked in the resident's room drawer; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2023
Plan of Correction
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Administrator shall submit a written plan of correction that states how this deficiency was corrected. In addition, proof of staff training by tomorrow.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 in that kitchen cabinet under the sink had unlocked knives, knives and scissors were found unlocked in drawers (photos taken), and laundry room was opened with access to detergents and cleaning supplies; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2023
Plan of Correction
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Administrator shall sumit proof of staff training and a written plan of correction by tomorrow.
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: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 06/23/2023 04:23 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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 the main entrance door auditory alarm was turned off and side door's auditory alarm is not operable; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2023
Plan of Correction
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Administrator shall provide proof that the auditory alarm on the side door is operable, and a written plan of correction that addresses the main entrance auditory alarm being turned off by staff. Submit by tomorrow.
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: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 06/23/2023 04:23 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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 in that a file for on-call staff (S2) was not on premises; which poses/posed a potential health, safety or personal rights risk to persons in care. NOTE: S2 is cleared and associated, but file was not available.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator shall submit self certification that file for on-call staff (S2) has been created, training has been completed, and is placed in facility premises.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 in that resident (R5's) physician report is dated 2/10/2020; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator shall submit a copy of R5's updated Physician Report.
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: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


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
VISIT DATE: 06/23/2023
NARRATIVE
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Residents with Special Health Needs:
  • No residents are receiving home health or hospice services.
  • Postural support physician orders are on file.
  • Half rails for mobility assistance were observed in some resident beds.
  • Individual Service Plans and Appraisals were observed in resident files.
  • No residents have prohibited health conditions.


NOTE: Change of Administrator is pending.

Per California Code of Regulations, Title 22, deficiencies were cited.



Exit interview was conducted with staff Maria Lerma. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7