198601953-1-27-2025-28-AS-BPEA-DDC3AY-20250127170531

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601953
Report Date: 01/27/2025
Date Signed: 01/27/2025 05:05:55 PM

Document Has Been Signed on 01/27/2025 05:05 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:	KENSINGTON SIERRA MADRE, THE		FACILITY NUMBER:	198601953
ADMINISTRATOR/ DIRECTOR:	CECILIA DEGRAFF		FACILITY TYPE:	740
ADDRESS:	245 W. SIERRA MADRE BLVD.		TELEPHONE:	(626) 355-5700
CITY:	SIERRA MADRE	STATE: CA	ZIP CODE:	91024
CAPACITY: 106	TOTAL ENROLLED CHILDREN: 0	CENSUS: 89	DATE:	01/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:47 AM
MET WITH:	Cecilia 'CC' DeGraff - Senior Executive Director		TIME VISIT/ INSPECTION COMPLETED:	04:15 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	Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA met with Cecilia DeGraff, Senior Executive Director and explained the purpose of the visit. The facility is licensed to serve (106) residents non-ambulatory residents of which (16) may be bedridden. Facility may retain up to (20) hospice residents and cleared for delayed egress. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date. Operational Requirements: Infection Control and Dementia plans have been added to the Plan of Operation.The facility passed the annual fire inspection conducted by Hill Top alarms on 09/05/2024. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2025. Fire and disaster drills were last conducted on 01/21/2025. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The Facility is 2 story building located in Sierra Madre, CA. A tour of the facility included: 1st floor (assisted living units with private bath), 42 resident units, large dining room, private dining room, kitchen, bistro, library, cinema, laundry room, multiple staff offices, medication/nurse station, 2 activity rooms, an elevator, public restrooms and 2 courtyards/patios. 2nd floor: (memory care units with private bath – 2 sections “Haven”-late-stage memory care and “Connections”-mild to moderate memory care), 25 units each with private bath; each side of memory care had their own dining area, kitchenette, activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The facility has central air/heating, call buttons in each unit and emergency sprinkler system throughout. The facility has central air and heating accommodations. The fire extinguishers were observed to be fully charged and in compliance. Kitchen was inspected, knives, cleaning solutions, and disinfectants are locked and inaccessible to residents. Kitchen staff were observed wearing hairnets and gloves while preparing lunch for residents. LPA toured random resident rooms and observed each bedroom to contain the required furniture and linens. Bathrooms were observed to be clean and equipped with operational grab bars. The signal system was tested in various locations and is operable. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit which complies with Title 22 Regulations. *CONTINUED ON LIC 809-C

David Sicairos	TELEPHONE: (323) 981-3982
Bennette Pena	TELEPHONE: (323) 981-3307
	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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: KENSINGTON SIERRA MADRE, THE	FACILITY NUMBER: 198601953
	VISIT DATE: 01/27/2025

NARRATIVE

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Staffing: A total of (139) staff members on the roster list including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Night shift staff are trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 04/27/2026.
Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records.
Residents Rights-Information: The facility has the following posters posted on each floor: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. Per staff, facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities.
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. Sanitation practices and kitchen cleanliness was observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food.
Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Medical and dental transportation is provided.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. The last drill was conducted on 01/21/2025.
Residents with Special Health Needs: Facility admits and retains residents with dementia and staff files reviewed today all have required training documented.

No deficiencies cited. Exit interview held and a copy of the report was provided to Administrator/Executive Director Cecilia “CC” Degraff.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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