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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602022
Report Date: 04/15/2023
Date Signed: 04/15/2023 03:39:11 PM

Document Has Been Signed on 04/15/2023 03:39 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:HALLDALE MANORFACILITY NUMBER:
198602022
ADMINISTRATOR:BUSTOS, GLENDAFACILITY TYPE:
740
ADDRESS:23438 HALLDALE AVENUETELEPHONE:
(310) 533-7364
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 5DATE:
04/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Emil & Virgina Romano TIME COMPLETED:
03:37 PM
NARRATIVE
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On 04/15/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with caregivers Emil and Virginia Romano. LPA explained the purpose of today’s visit. Romano contacted administrators Glenda Bustos and Melanie Tallada both unavailable to be present for the visit. The facility is licensed to operate for (6) non-ambulatory elderly adults of which (1) may be bedridden ages 60 and above. Currently, the facility has (5) residents and (1) in hospice care. The facility is approved for (2) hospice residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (1) a live-in staff room, (3) bathrooms, a living/activity room, a dining area, a kitchen, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 106.5 degrees F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed First Aid Kit was maintained. A working landline phone was operational.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022
VISIT DATE: 04/15/2023
NARRATIVE
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LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An audit of resident #1-#5 (R1-R5) service files and staff #1-#5 (S1-S5) personnel files and it revealed incomplete. (see LIC 858 and 859)

DEFICIENCIES:
  • Smoke Detectors: non-operable in rooms #2 and #4 – Type A
  • Postural Support: non-authorized full bed rails for resident #2 – Type A
  • Carbon Monoxide: non operable in dining room area - Type A
  • Disinfectants/Toxic Cleaning Solutions: Accessible in patio and bathroom #1 – Type A
  • Bathroom #1 Exhaust Fan: Non-operable – Type B
  • Bathroom #1 Cabinet Door: Non-operable – Type B
  • Administrators Certificate: Expired for Staff #3 – Type B
  • Personnel files: Incomplete for staff #1, #2, #4 and #5 – Type B
  • Resident files: Incomplete for resident #1, #2 #3, #4 and #5 (no service file #3) – Type B
  • Staff #4 and #5: No CPR certificate on file - Type B
  • Bathroom trash bins: No lids/covers to prevent transmission of communicable disease or odors. Type B
  • Administrator's Qualification: Failed to conform to applicable rules and regulations, which resulted to multiple citations.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

In light of no administrators available for this inspection visit, LPA unable to complete the CARES inspection Tool. Unable to obtain a copy of a Liability Insurance. Annual continuation is required to complete this annual inspection.

An exit interview conducted with Emil Romano and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2023
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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 12:45 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section. LPA identified a non-working Carbon Monoxide filed away in a metal cabinet. This violaton poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2023
Plan of Correction
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The licensee/administrator will purchase a new working carbon monoxide. Proof of correction is due by POC date: 04/16/23 sent by fax to 323-981-1781.
Type A
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
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Based on [(observation) (interview), the licensee did not comply with the section cited above. LPA identified cleaning/disfectant solutions in patio and bathroom #1 accessible to dementia residents. This violation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2023
Plan of Correction
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The licensee/administrator will immediately store in lock storage any toxic/hazardous materials accessible to residents in care. Proof of correction is due by POC date: 04/16/23 sent by fax to 323-981-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 12:45 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on [(observation) (interview), the licensee did not comply with the section cited above. LPA observed a non working bathroom exhaust fan and broken cabinet door in bathroom #1. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2023
Plan of Correction
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The Licensee/Administrator will ensure to have bathroom exhaust fan and broken cabinet door repaired by POC due date: 05/06/23 sent by fax to 323-981-1781.
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section. LPA identified trash bins in bathroom did not have lids/covers to prevent transmission of communical disease or odors. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The Licensee/Administrator will ensure to replace exisiting trash bins with lids to prevent transmission of communicable germs or odors. Proof of correction must be sent by POC due date: 04/22/23 by fax to 323-91-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 12:46 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited. LPA identified staff #4 & #5 (live-in staffs) did not have CPR Training Certificates. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The Licensee/Administrator will ensure all employed staff are trained/completed CPR training. Proof of correction must be sent to by POC due date: 04/22/23 by fax to 323-981-1781.
Type B
Section Cited
CCR
87405(1)(2)
Other Provisions
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. The admnistrator failed to conform to applicable rules and regulations, which resulted to multiple citations.This violaitoin which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2023
Plan of Correction
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The Licensee/Administrator will review Title 22 section 87405 and sent a copy of a written statement stating Section 87405 was reviewed and will adhere to the rules and regulations of Title 22. Proof of correction must be sent by POC due date: 04/22/23 by fax to 323-981.1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 01:21 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(5)(B)
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. Resident #2 has full bed rails and did not have authorized PCP or hospice approval. According to staff #3, he placed the full rails to prevent the resident from falling off bed. This violaiton poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2023
Plan of Correction
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The Licensee/Administrator will adhere to Title 22 Section 87608 will remove full bed rails as restraint. Otherwise, a PCP or hospice authorization is required to have full bed rails for residents in care. Proof of correction is due by 04/16/23 by fax to 323-918-1781.
Type A
Section Cited
CCR
87468.1(2)
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview), the licensee did not comply with the section cited above. LPA identified (2) non working smoke detectors in resident rooms #2 and #4. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2023
Plan of Correction
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The Licensee/Administrator will immediately replace non-working smoke detectors by proof of correction due date: 04/16/23. POC must be sent by fax to 323-981-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 01:38 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)(17)(A-F)
a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. LPA identified all (5) residents did not have complete or curerrent required records on file. This violaiton poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2023
Plan of Correction
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The Licensee/Administrator will review all residents (R1-R5) files and ensure that all missing required documents are complete and current. Proof of correction must be sent by POC due date 05/06/23 by fax to 323-981-1781.
Type B
Section Cited
CCR
87412(a)(1-13)(c)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review), the licensee did not comply with the section cited above. Licensee failed to have complete or current required records for each staff including required medical trainings. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2023
Plan of Correction
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3
4
The Licensee/Administrator will adhere to Title 22 Section 87412 and ensure that all staff required documents are complete and current including medical trainings. Proof of correction must be sent by POC due date: 0506/23 by fax to 323-981-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


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Document Has Been Signed on 04/15/2023 03:39 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 04/15/2023 at 02:09 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HALLDALE MANOR
FACILITY NUMBER: 198602022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064.2(h)(1)
(h) Certificates shall be valid for a period of two (2) years and expire on either the anniversary date of initial issuance or on the individual's birthday during the second calendar year following certification. (1) The certificate holder shall make an irrevocable election to have his or her recertification date for any subsequent recertification either on the date two years from the date of issuance of the certificate or on the individual's birthday during the second calendar year following certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (observation) (record review) the licensee did not comply with the section cited above. LPA identifid staff #3 did not have a current administrators certificate which expired on 07/18/22. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2023
Plan of Correction
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4
The Licensee/Administrator shall review the Title 22 Section 85064.2 regulations and comply. The administrator will apply to be recertified for administrator's certification immediately. A proof of must be sent by the POC due date: 05/06/23 by fax 323-981-1781.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2023


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