198602955-9-10-2024-28-AS-SVAD-D8Z3VB-20240910183452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602955
Report Date: 09/10/2024
Date Signed: 09/10/2024 06:34:59 PM

Document Has Been Signed on 09/10/2024 06:34 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CARINDALE RESIDENTIAL CARE		FACILITY NUMBER:	198602955
ADMINISTRATOR:	NARVAEZ, JANET		FACILITY TYPE:	740
ADDRESS:	1342 S. BARRANCA		TELEPHONE:	(626) 426-1369
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator, Ralph Estanisloa		TIME COMPLETED:	03:15 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)S Vaid made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the CARE tool to evaluate the facility. LPA Vaid met with Caregiver Angela Gavilanes and explained the purpose for the visit. Angela called the administrator/licensee Ralph Estanislao arrived shortly after and helped with the visit. LPA conducted a tour of the physical plant with Ralph observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and client's medications. The facility has an approved mitigation plan on file. The facility is a two-story home located in a residential area. It is licensed to serve (6) elderly residents, ages 60 and over, of which all may be non-ambulatory and (1) may be bedridden and has a hospice waiver approved for 2. The home consists of a living room, kitchen, dining room, (6) resident bedrooms, (1) staff room located upstairs, (2) bathrooms, (1) staff/visitor bathroom, a shaded patio in the backyard with seating, and a detached garage. LPA observed all resident bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. (2) resident bathrooms were observed to have a shower, toilet, and wash basin. LPA observed cleaning supplies and toxins locked and inaccessible to residents. The showers accommodate non-ambulatory clients and have the required grab-bars and non-skid mats. The water temperature was tested and measured are in-compliance. The food supplies were observed to be the required 2-day perishables and 7-day non-perishables. Several fire extinguishers were observed throughout the facility. They had current inspections and were fully charged, lasted tested 09/20/2023. The first aid kit was inspected and had the required items, as well as a current first aid manual. All sharps were observed to be locked and inaccessible in a drawer in a file cabinet near the kitchen. Other cleaning supplies were locked and inaccessible, in hallway closet. All equipment was operational and in good repair. A hallway closet had additional towels and linens for clients. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. Continued on 809C.....

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CARINDALE RESIDENTIAL CARE	FACILITY NUMBER: 198602955
	VISIT DATE: 09/10/2024

NARRATIVE

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Medications are centrally stored in a file cabinet near the kitchen along with resident and staff files. There is a fish pond in the backyard that has a fence around the entire perimeter, LPA observed the pond to be drained and has no water. The facility has cameras in the common areas. According to staff, the cameras are do not record, they are only used for surveillance.

LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in a closet inside bathroom# 1. Additional PPE was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors. PPE signage was observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing, as required by infection control practices. All hand washing stations were noted to have paper towels.

All resident files were reviewed and had updated emergency contact information and health screenings. (3) staff files were reviewed and had Criminal Background Clearances and health screenings. Certification for the staff were observed and are in compliance. All resident medications were reviewed. Four (4) residents’ medications were reviewed, LPA observed the MARs was being used to document administration of the medication. LPA observed all residents to have full bed railings on their beds, all four residents have physician orders for full railing.

No deficiencies were observed on today’s visit. An exit interview was conducted with Administrator Estanislao and a copy of this report and were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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