<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601845
Report Date: 07/18/2024
Date Signed: 07/18/2024 05:11:56 PM

Document Has Been Signed on 07/18/2024 05:11 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:A SPLENDOR LIVING - THE GLENDORA INCFACILITY NUMBER:
198601845
ADMINISTRATOR/
DIRECTOR:		CHRIS JENGFACILITY TYPE:
740
ADDRESS:452 SELLERS ST.TELEPHONE:
(626) 594-0152
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 34CENSUS: 7DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Administrator Rachel De Chavez TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
This facility is licensed to serve thirty four (34) non-ambulatory residents over the age of 60. This facility may retain no more than eight (08) hospice residents. There are two (02) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Total census for this facility is seven (07). Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Administrator Rachel De Chavez purpose of today’s visit. Surveillance cameras were observed in common areas of the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected seven (7) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. LPA Ramirez observed discarded roofing material, shopping cart, several tera cotta bricks, several empty paint bucks, ladder, and broken-down commercial refrigerator in the facility backyard/side parking lot. LPA Ramirez will issue Type B deficiency based on this observation.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed a posted facility activity schedule upon entrance to the facility.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.

SEE 809-C for continuation.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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 4
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: A SPLENDOR LIVING - THE GLENDORA INC
FACILITY NUMBER: 198601845
VISIT DATE: 07/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 06/20/2024 and 04/29/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.

Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order in four (4) out of the five (5) exit doors equipped with an auditory device. Sliding door exit auditory device was not in good repair when tested. LPA Ramirez will issue Type B deficiency based on this observation.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Rachel De Chavez expires 11/08/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. During personnel records review, LPA Ramirez did not observe documentation indicating the licensee reported to this licensing agency, a new administrator was hired in December of 2023. LPA Ramirez will issue Type B deficiency based on records review.

Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.


Operational Requirements: The fire clearance is approved for thirty-four (34) non-ambulatory. This facility may retain no more than eight (08) hospice residents. There are two (02) residents under hospice care.
Resident Records/Incident Reports: LPA reviewed resident files for seven (7) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.
Three (3) deficiencies were cited today. Exit interview was conducted and copy of this report, 809-D and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/18/2024 05:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/18/2024 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A SPLENDOR LIVING - THE GLENDORA INC
FACILITY NUMBER: 198601845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87211(g)(1)(2)(3)(A)
87211 Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:(1) Name and residence and mailing addresses of the new administrator.(2) Date he/she assumed his/her position.(3) Description of his/her background and qualifications, including documentation of required education and administrator certification. (A) A photocopy of the documentation is acceptable.
This requirement is not met as evidenced by:
Licensee did not notify this licensing agency when a new administrator was hired on 12/04/2023.
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not notify the department when a new administrator was hired in 12/4/2023, the licensee did not comply with the section cited above in 7 out of 7 clients, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
1
2
3
4
Licensee will review above regulation and certify a plan to notify this department and provide documentation for new administrator change.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) 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:
Disgarded roofing supplies, shopping cart, broken down commercial fridge and several empty paint buckets were observed in backyard near basketball courts.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above 7 out of 7 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
1
2
3
4
Licensee will remove debris and roofing material from backyard/ courtyard area and provide invoice of hauling removal.
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
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/18/2024 05:11 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/18/2024 at 04:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A SPLENDOR LIVING - THE GLENDORA INC
FACILITY NUMBER: 198601845

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705 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:
Auditory device on sliding door exit was not in good repair.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 7 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
1
2
3
4
Licensee will repair or replace auditory device and send picture proof via email.
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
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4