198602961-10-3-2024-28-AS-BPEA-D9PVL7-20241003163127

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602961
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:31:42 PM

Document Has Been Signed on 10/03/2024 04:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	REDELL PINE LLC		FACILITY NUMBER:	198602961
ADMINISTRATOR:	POSTALDJIAN, ARA		FACILITY TYPE:	740
ADDRESS:	2131 REDELL AVE		TELEPHONE:	(626) 408-5700
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	6	CENSUS: 6	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ara Postaldjian - Administrator		TIME COMPLETED:	04:30 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) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Gina Abegunde, Caregiver and Ara Postaldjian, Administrator and explained the purpose of the visit. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) non ambulatory of which (1) may be bedridden. There is an approved hospice waiver for (2) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathroom has hygiene items such as hand soap, paper towel and toilet paper. Operational Requirements: Plan of Operation was reviewed. The Infection Control Plan and Dementia plan have been added to the Plan. A fire clearance is in place. Last Fire Drill was conducted on 09/06/2024 and training is conducted on a quarterly basis. Liability Insurance policy is valid and expires on 12/19/2024. Facility does not handle cash resources for the residents. Facility has working signal systems in exit points which were tested and observed to be operational. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of (4) resident bedrooms, (3) bathrooms, living room, kitchen, dining area, laundry area, detached garage, and backyard. Currently, there are three (3) non ambulatory and (3) ambulatory residents living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke/carbon monoxide detector, linen, dresser, light, chair and sufficient closet space. There are (2) residents under hospice care, (1) with full bed rail and total of (4) residents with 1/2 bed rails. Exit doors have auditory device and free of any obstruction. Backyard was inspected and has a shaded area and sitting area. There are no pools or large bodies of water. The kitchen was observed to have sufficient amount of perishable and non-perishable food supplies. Laundry area is located in the kitchen area. Cleaning supplies and toxic substances are inaccessible to residents. The facility is equipped with cameras without audio in the common areas. LPA observed (2) fire extinguishers that were full. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 110.8 deg F in bathroom #1, 107.2 deg F in bathroom #2 and 106.8 deg F in bathroom #3. ***REPORT CONTINUED ON LIC809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: REDELL PINE LLC	FACILITY NUMBER: 198602961
	VISIT DATE: 10/03/2024

NARRATIVE

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Staffing: A total of thirteen (13) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 09/15/2025.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Incidental Medical Services: There is zero (0) resident with a restricted health condition.
Resident Records-Incident Reports: LPA reviewed (6) resident files. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Appraisal/Needs and Services plan, I.D. and Emergency Information, Consent for Medical Treatment, Resident Personal Property and Resident Personal Rights observed.
Health Related Services: Medications were reviewed for (4) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log and medication list to document medications given. Medications are administered as prescribed by the Physician.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.
Residents with SHN: (6) residents are incontinent, (1) diabetic and (2) are using oxygen.

Deficiencies cited. Exit interview and a copy of this report along with the appeal rights were provided to
Ara Postaldjian, Administrator.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/03/2024 04:31 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
GREATER LA AC/SC, 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the Administrator did not comply with the section cited above in that LPA observed (4) residents with double half bed rails and Administrator stated that the facility did not have a doctor’s order for the (3) residents with half bed rails which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain doctor's orders for the (3) residents using double 1/2 bedrails and will read section 87608 and send a written letter to LPA stating that he read, reviewed and understood the section cited. These documents will be submitted to CCL/LPA by POC due date.

Type B

Section Cited

CCR

87618(b)(3)(B)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the Administrator did not comply with the section cited above in which LPA observed (2) residents using oxygen but there's no "no smoking-oxygen in use” signs posted in the appropriate rooms/areas which poses/posed a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 10/03/2024
	Plan of Correction
1 2 3 4	Administrator printed the "no smoking-oxygen in use’ and posted it on the residents’ doors. *DEFICIENCY CLEARED DURING THE VISIT.***

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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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