198601845-7-13-2023-28-AS-ALOZ-CTPV5N-20230713160813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601845
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:08:36 PM

Document Has Been Signed on 07/13/2023 04:08 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 INC		FACILITY NUMBER:	198601845
ADMINISTRATOR:	CHRIS JENG		FACILITY TYPE:	740
ADDRESS:	452 SELLERS ST.		TELEPHONE:	(626) 594-0152
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91741
CAPACITY:	34	CENSUS: 8	DATE:	07/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:28 AM
MET WITH:	Mellisa Flores, Administrator and Caitlin Hildalgo		TIME COMPLETED:	04:29 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Assistant Administrator Caitlin Hildalgo and LPA explained the purpose of the visit. Administrator Melissa Flores arrived a short time later. The facility has a capacity of 34 residents. It is licensed to serve elderly residents age 60 and above, approved for 34 non-ambulatory residents. Facility is approved for 8 hospice waivers. The facility cares for elderly residents with dementia. Administrator certificate is current and expires on 8/12/2023.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene, mask and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies.
Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility does not have proof on file of enough liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: The facility is in a residential neighborhood and consisted of 17 resident’s bedrooms, 13 bathrooms, living room, kitchen, dining room, activity room, medication room, and activity area at the patio. Facility has operable fire alarm and sprinkler system; Knives are inaccessible to client. There was toilet cleaner bleach in the bathroom of one resident room. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms sink. The hot water temperature in the measured between 126.3 degrees F which is not between the required range of 105-120 degrees. Door by the activity room needs repair. The rails along the common hallway are in disrepair. Debris room 7 shower need to be removed. Windowsill in room is uncleaned.
Staffing: There appears to be sufficient staffing at the facility. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Some staff no not have current CPR/first aid training and no evidence of on-going training.

(Continue on 809D)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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
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: 07/13/2023

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Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-Admission Appraisal is missing on all residents.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Facility is missing the LET US KNOW poster.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 4 residents' medication files and medication is being administered according to doctor’s orders. PRN medications are missing PRN authorization letters.
Disaster Preparedness: The facility has Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. No Smoking - Oxygen in use signs are not posted on the doors of residents using oxygen.

During the visit today, LPA observed deficiencies and are indicated on the LIC809D.

Deficiencies sited (See 809D) and technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Administrator Melissa Flores

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/13/2023 04:08 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Water measured 126.3 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Licensee will adjust water and send proof to LPA by POC.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 15

Document Has Been Signed on 07/13/2023 04:08 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility did not have on hand the proof of liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Licensee will send proof of insurance to LPA by POC date.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Railings need repair or replacement. Door in activity room needs repair or replacement. Debris in the back need to be removed. Items in bathroom shower in room 7 need to be removed. Window sill in room 2 needs to be cleaned.The door in conference room needs to be repaired or replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	Licensee will repair or replace all items above by POC date and send to proof to LPA by POC 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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 4 of 15

Document Has Been Signed on 07/13/2023 04:08 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above toilet cleaner with bleach was in residents bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2023
	Plan of Correction
1 2 3 4	Administrator removed the toilet cleaner bleach during visit. ***no further action required**

Type B

Section Cited

CCR

87415(a)

Night Supervision

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview record review, the licensee did not comply with the section cited above One night shift staff did not have CPR/first aid certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Administrator will send proof of correction to LPA by POC 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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 5 of 15

Document Has Been Signed on 07/13/2023 04:08 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
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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. There are garden tools in back yard which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Licensee will make all tools inaccessible to residents.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 6 of 15