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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601953
Report Date: 03/03/2022
Date Signed: 03/08/2022 02:35:42 PM


Document Has Been Signed on 03/08/2022 02:35 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:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR:CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:106CENSUS: 84DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Nursing / Stephanie Peck
Wellness Nurse / Daniel Orozco
Executive Director / Cecilia "CC" Degraff		TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Director of Nursing / Stephanie Peck and Wellness Nurse / Daniel Orozco and was later joined by the Executive Director / Cecilia "CC" Degraff who assisted with the visit. The facility is licensed to serve for a capacity of 106 residents (90 Non-ambulatory and 16 Bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for twenty (20) Residents. The Kensington Sierra Madre has an approved Dementia Care Plan in its plan of operation and accepts/cares for residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The first floor consists of 41 resident rooms, lobby/reception area, parlor, art studio/gallery, cinema room, library, dining room, cafe area and main kitchen. The second floor consists of the Memory Care Units, 1) Connection with 19 rooms for residents with mild to moderate dementia and 2) Haven with 15 rooms for late to end stage dementia. Each unit has a dining area, kitchen, activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations.

LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have signal systems located in each bathroom and facility phones to call the front desk. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility.

(Please see LIC 809C for additional information)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 03/03/2022
NARRATIVE
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The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has carbon monoxide detectors in each resident room and in the hallways of the facility. A shaded area with chairs is provided to the residents.

Medications are centrally stored in the locked medication carts located on each floor. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician.

The following deficiencies were observed during today's visit;
  • Between the hours of 10:45am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. Men's room located on the first floor (near the bistro/parlor) was measured at 123.8 degrees F. Kitchen in Connection was measured at 123.9 degrees F. Activity room in Connection was measured at 121 degrees F. Kitchen located in room #238 was measured at 121 degrees F. Kitchen located in room #219 was measured at 122.5 degrees F. Bathroom located in room #219 was measured at 120.4 degrees F. Kitchen located in room #223 was measured at 120.5 degrees F. Kitchen in Haven was measured at 122.8 degrees F. Activity room in Haven was measured at 121.6 degrees F.
  • At 11:26AM, Peroxide Multi Surface Cleaner /Disinfectant Spray and Vision Lens Cleaner were found in room #230, which is located in Connection.
  • At 12:42pm, LPA discovered the following PRN medications were prescribed by Resident 1's (R1's) physician but were missing from the facility. ENEMA 19G-7G/ ML (Administer 1 Enema rectally every 48 hours as needed for constipation) & MI-ACID 400-400-40 MG (Take 2 tablespoonfuls 30ML by mouth every 4 hours as needed).


The following deficiencies were observed to be in violation under California Code of Regulations Title 22.
(refer to 809D).
An exit interview was conducted and a copy of this report was provided to the Executive Director along with the appeals rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/08/2022 02:35 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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2022
Section Cited

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Maintenance and Operation. 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 degree C) and not more than 120 degree F
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(49 degree C).
This requirement is not met as evidenced;
Between the hours of 10:45am - 12:30pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. Men's room located on the first floor (near the bistro/parlor) was measured at 123.8 degrees F. Kitchen in Connection was measured at 123.9 degrees F. Activity room in Connection was measured at 121 degrees F. Kitchen located in room #238 was measured at 121 degrees F. Kitchen located in room #219 was measured at 122.5 degrees F. Bathroom located in room #219 was measured at 120.4 degrees F. Kitchen located in room #223 was measured at 120.5 degrees F. Kitchen in Haven was measured at 122.8 degrees F. Activity room in Haven was measured at 121.6 degrees F. This poses an immediate health, safety risk to persons in care.
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***Citation was cleared at the time of visit
and no further action is needed***
Type A
03/03/2022
Section Cited

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Care of Persons with Dementia. Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced;
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At 11:26AM, Peroxide Multi Surface Cleaner /Disinfectant Spray and Vision Lens Cleaner were found in room #230, which is located in Connection. This poses an immediate health, safety risk to persons in care.
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***Citation was cleared at the time of visit
and no further action is needed***
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) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4


Document Has Been Signed on 03/08/2022 02:35 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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2022
Section Cited

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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced;
At 12:42pm, LPA discovered the following PRN medications were prescribed by Resident 1's (R1's) physician but were missing from the
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facility.
ENEMA 19G-7G/ ML (Administer 1 Enema rectally every 48 hours as needed for constipation) & MI-ACID 400-400-40 MG (Take 2 tablespoonfuls 30ML by mouth every 4 hours as needed). This poses an immediate health, safety risk to persons in care.
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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) 981-3969
LICENSING EVALUATOR NAME: Joe KatrdzhyanTELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4