198602551-1-9-2024-28-AS-NGAA-CZBVXV-20240109155009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602551
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:50:16 PM

Document Has Been Signed on 01/09/2024 03:50 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:	HOME AWAY ASSISTED LIVING		FACILITY NUMBER:	198602551
ADMINISTRATOR:	KISS, ADRIANA REY		FACILITY TYPE:	740
ADDRESS:	8743 YOUNGDALE STREET		TELEPHONE:	(626) 731-3244
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 0	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:03 PM
MET WITH:	Adriana Kiss, Administrator		TIME COMPLETED:	03:50 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to staff Zoltan Kiss. Administrator Adriana Kiss arrived shortly after. There are currently zero (0) 4 elderly residents in care. Twelve 12 (CARE) tool domains were utilized during the inspection.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. Staff are no longer wearing masks or screening visitors. A visitor sign-in station is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:

A current Plan of Operation was reviewed.
The facility has a Dementia Waiver in place. A Hospice Waiver for one (1) is approved.
Facility has a fire clearance for 6 non-ambulatory adults 60 and over, of which one (1) may be bedridden.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expired 7/13/2023. Licensee has not renewed policy since there are zero (0) residents in care.
A surety bond is not applicable. Facility does not handle resident's money.

***Narrative continues next page.****

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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: HOME AWAY ASSISTED LIVING	FACILITY NUMBER: 198602551
	VISIT DATE: 01/09/2024

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Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood consisting of 3 resident bedrooms, 2 staff bedrooms, living room, dining room, kitchen, laundry room, 3 bathrooms, backyard patio area, detached garage, and a building/ ADU (Additional Dwelling Unit) in the rear of the property. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Exit doors are free of any obstruction.
The facility has one two (2) fully charged fire extinguishers, operable smoke and carbon monoxide detectors.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

The facility is owner operated. Criminal Background Clearance was checked. It presently does not have any residents in care.

Personnel Records/Staff Training:

Administrator certificates expires 5/10/2024.
Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training was observed in staff files.

Resident Records/Incident Reports:

No resident files were reviewed. There are no residents in the home.
RCFE complaint poster and Personal rights were observed posted.

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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: HOME AWAY ASSISTED LIVING	FACILITY NUMBER: 198602551
	VISIT DATE: 01/09/2024

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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.

Incident Medical and Dental:

Centrally stored medicines are kept safe and locked in hallway closet. No resident medications were reviewed.
Medical and dental transportation is provided by family members and 3rd party transportation services.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610D was reviewed and is updated.
The last emergency disaster drill was conducted on 1/2/2024.
1st Aid Kit & Manual were observed.

Residents with Special Health Needs:

No residents are in care. Therefore, there is no home health or hospice care in place.
Bedrooms contained mandated furniture/linens, and bathrooms are clean and operational.

No deficiencies were cited.

Exit interview was conducted with Administrator Adriana Kiss. A copy of the report was not issued due to printing issues. LPA will mail a copy to Licensee.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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