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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602961
Report Date: 09/09/2022
Date Signed: 02/03/2023 10:23:56 AM

Document Has Been Signed on 02/03/2023 10:23 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:REDELL PINE LLCFACILITY NUMBER:
198602961
ADMINISTRATOR:POSTALDJIAN, ARAFACILITY TYPE:
740
ADDRESS:2131 REDELL AVETELEPHONE:
(626) 408-5700
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 6CENSUS: 5DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff / Gina Abegunde
Administrator / Ara Postaldjian		TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Staff / Gina Abegunde and was later joined by the Administrator / Ara Postaldjian who assisted with the visit. The facility is licensed to serve for a capacity of six (6) Residents ages 60 and over. The facility has an approved fire clearance for five non-ambulatory residents and one bedridden resident. Hospice care waiver approved for two (2) residents. Currently, there are five (5) residents in placement. There are zero (0) bedridden residents and zero (0) residents receiving hospice services. LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed.

The facility is located in a residential area. A tour of the single-story facility includes: four (4) resident bedrooms, two (2) resident bathrooms, one (1) staff bathroom, living room, dining room, kitchen, laundry area and unattached garage/storage/office.

The bathrooms are clean and operational. Resident bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines. The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for cleaning solutions, toxins, knives, and hazardous items are in a secured cabinet and inaccessible to residents. The first-aid kit is fully stocked w/First-aid Manual. LPA reviewed resident medications.

Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers (2) were observed to be fully charged and in compliance. There is a functioning telephone on the premises. he facility has central AC and heating accommodations. The washer and dryer are located in the kitchen area, next to the pantry. A shaded area with chairs is provided in the back yard. The backyard is free of
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: REDELL PINE LLC
FACILITY NUMBER: 198602961
VISIT DATE: 09/09/2022
NARRATIVE
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debris/hazards and the outdoor and passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. There are no security bars or weapons on the premises. There is no evidence of bodies of water (pool) on the premises. All required documents are posted inside the facility.

During today's walk through, LPA observed COVID-19 prevention/protocol signs posted throughout the facility.

The following concerns were observed during today's visit;

  • During a walk through of the inside physical plant, LPA found disposable razors in the bathroom located in bedroom #4, left accessible to residents with dementia.
  • The lock on the medication cabinet doors was in disrepair, making medications accessible to resident with dementia.
  • During a walk through of the outside physical plant, LPA observed that the self closing mechanism/latch on the exit gates located on each side of the facility were inoperable and the gates would not self close.
  • The side exit door located in the kitchen had a broken handle which needed to be repaired/replaced.


The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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Document Has Been Signed on 02/03/2023 10:23 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 09/09/2022 at 12:42 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REDELL PINE LLC
FACILITY NUMBER: 198602961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by: During a walk through of the inside physical plant, LPA found disposable razors in the
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bathroom located in bedroom
#4, left accessible to residents with dementia. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/09/2022
Section Cited

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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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The lock on the medication cabinet doors was in disrepair, making medications accessible to resident with dementia. This poses an immediate health, safety or personal rights risk to persons 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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


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Document Has Been Signed on 02/03/2023 10:23 AM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 09/09/2022 at 12:59 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REDELL PINE LLC
FACILITY NUMBER: 198602961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited

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Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
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During a walk through of the outside physical plant, LPA observed that the self closing mechanism/latch on the exit gates located on each side of the facility were inoperable and the gates would not self close.
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Type B
09/11/2022
Section Cited

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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:
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The side exit door located in the kitchen had a broken handle which needed to be repaired/replaced.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


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