198601951-5-27-2023-28-AS-BPEA-CS8RHA-20230527130202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601951
Report Date: 05/27/2023
Date Signed: 05/27/2023 01:02:24 PM

Document Has Been Signed on 05/27/2023 01:02 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:	EL MOLINO ROSE VILLA		FACILITY NUMBER:	198601951
ADMINISTRATOR:	ANDREI KOHLER		FACILITY TYPE:	740
ADDRESS:	1144 N. EL MOLINO AVENUE		TELEPHONE:	(626) 660-5750
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	6	CENSUS: 6	DATE:	05/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Administrator, Andrei Kohler		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Brisia Rojas, Caregiver and explained the purpose of today's visit. Administrators Andrei Kohler and Yelly Kohler greeted LPA shortly after and assisted with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy (policy # 000937293) in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 6/23/2023. The last fire Drill was conducted on 03/05/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: he facility is a single story home located in a residential neighborhood that is licensed to serve 6 non-ambulatory residents ages 60 and over, may retain 4 hospice residents. Current census is six (6) non ambulatory of which three (3) are under hospice care. Home consists of four (4) resident bedrooms, 2 bathrooms (1 full and 1 1/2), living room, dining room, medication/TV room, kitchen, backyard, and a detached garage being used as a private residence for the Administrators, Andrei and Yelly Kohler. 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. Smoke and carbon monoxide detectors are operational. The facility has (3) fire extinguishers in the facility. One (1) fire extinguisher located in the kitchen was purchased on 6/20/2022. The other (2) fire extinguishers were purchased on 5/20/2022 and the Administrator stated that they will purchase new ones. LPA reviewed the fire inspection report conducted and completed by Pasadena Fire Dept. on 4/30/2023. Cleaning supplies and toxic substances are inaccessible to clients. At 10:50am, hot water temperature readings measured 116.2 deg F in the kitchen, 115.9 deg F in bathroom #1 and 109.5 deg F in bathroom #2 which are within the required 105-120 degrees Fahrenheit. *CONTINUED ON LIC 809-C

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

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: EL MOLINO ROSE VILLA	FACILITY NUMBER: 198601951
	VISIT DATE: 05/27/2023

NARRATIVE

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Staffing: A total of seven (7) caregivers including the (2) Administrators provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.

Personnel Records-Training: Administrator certificate expired on 5/14/2024. Three (3) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training.

Resident Records-Incident Reports: Six (6) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed.

Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails were reviewed in (6) residents files.

Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. One (1) resident attend the Day Program 2x a week. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained).Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Not currently, but Home Health personnel serviced the residents in the facility. Residents medication are centrally stored in a locked cabinet in the medication/TV room.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents.

Additional note from the Administrator, Andrei Kohler: A copy of the active workers compensation insurance with Biberk was provided to CCL on a voluntary basis.

Exit interview conducted and a copy of the report was provided to the Licensee/Administrator Andrei Kohler.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2023

LIC809 (FAS) - (06/04)

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