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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602908
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:54:06 PM


Document Has Been Signed on 03/05/2024 12:54 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:ST. CECILIA'S SENIOR HOME IIFACILITY NUMBER:
198602908
ADMINISTRATOR:VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:172 S. COUNTRY CLUB ROADTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tiffany Vander Poorten- Administrator/LicenseeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst's (LPA's) Val Maldonado and Tyler Reyes made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA's Maldonado and Reyes met with Administrator, Tiffany Vander Poorten, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, and conducted interviews with (3) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (6) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (2) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.
At about 9:10AM, upon entry to the facility, LPA's Maldonado and Reyes observed surveillance cameras in the dining room, living room, and TV room. This facility does not have approval to have surveillance cameras in use. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home. (1) bathroom is designated for resident use and one for staff/visitor use. Resident bathroom is equipped with required grab bars and non-skid mats for the shower. The hot water was tested and measured at 112.8*F, which is in compliance. Food supplies was observed and was sufficient as required. Emergency food supplies and water were available. First aid kit and manual were observed. There were no bodies of water observed on the premises. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted in January 2024. Auditory devices were observed at all entrances/exits of the home and were operational. Smoke/carbon monoxide detectors were tested and observed to be operational during the visit. (6) resident files and (3) staff files were reviewed and observed to be complete with all required documentation. (6) resident medications were reviewed and were observed to be documented properly and given as prescribed.
Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC809-D.
An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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Document Has Been Signed on 03/05/2024 12:54 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: ST. CECILIA'S SENIOR HOME II
FACILITY NUMBER: 198602908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in surveillance cameras in common areas of the facility without proper approval from the licensing agency, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee removed surveillance cameras immediately and will submit a written plan explaining how Licensee will ensure resident's personal rights are not violated and will follow process to request a waiver for camera use in the future. Plan to be emailed to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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