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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602393
Report Date: 04/30/2024
Date Signed: 04/30/2024 09:08:18 AM

Document Has Been Signed on 04/30/2024 09:08 AM - 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:ST. CECILIA'S SENIOR HOMEFACILITY NUMBER:
198602393
ADMINISTRATOR/
DIRECTOR:		VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:307 N BARRANCA AVETELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 0CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Yvette OliverosTIME VISIT/
INSPECTION COMPLETED:
09:07 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong generated this Case Management - Deficiencies evaluation report in conjunction with Complaint Control # 28-AS-20220601111916 and made the following observation. While LPA conducted the investigation and reviewed Resident#1 (R1)’s record and observed R1 does not have any medical assessment in file.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citation.

An exit interview was conducted, and a copy of the Report and Appeal Rights were provided to Caregiver Yvette Oliveros
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/30/2024 09:08 AM - It Cannot Be Edited


Created By: Christine Wong On 04/30/2024 at 08:59 AM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. CECILIA'S SENIOR HOME
FACILITY NUMBER: 198602393

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment (a)(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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The administrator will obtain and keep on file documentation of medication signed by a physician prior to a person’s acceptance as a resident. The administrator will send LPA the future plan about obtaining medical assessment prior to accept resident by POC due date.
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The requirment was not met as evidenced by
Record review, LPA was reviewing R1's record and did not observe the physician report in file before R1 admitted to the facility which posed a potential risk to residnet 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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