198602961-10-19-2023-28-AS-JVIS-CWS26Y-20231019170753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602961
Report Date: 10/19/2023
Date Signed: 10/19/2023 05:08:21 PM

Document Has Been Signed on 10/19/2023 05:08 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:	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:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Administrator Ara Postaldjian		TIME COMPLETED:	03:10 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 Analysts (LPA) Jose Villalobos 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 Administrator Ara Postaldjian. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan.

Operational Requirements:

A current Plan of Operation with Infection Control Plan observed. No Dementia Care Plan on file
A fire clearance for 6 residents of which (6) may be non ambulatory; 1 may be bedridden.
Hospice care waiver approved for two (2) residents.

Physical Plant/Environment Safety:

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 interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

A total of 8 staff members provide supervision to the residents.
Sufficient staff observed during visit

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 10/19/2023 05:08 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: REDELL PINE LLC	FACILITY NUMBER: 198602961
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(c)

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in as there is no dementia care plan on file and there are dementia residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to provide Licensing with a Dementia Care Plan for review by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 10/19/2023

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
26
27
28
29
30
31
32

Personnel Records/Staff Training:

Administrator on file is current.
Staff have criminal background clearance and training.
Four (4) staff files were reviewed. Required training observed

Resident Records/Incident Reports:

A total of six (6) resident files were reviewed.
Required postings observed

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
An activity calendar was reviewed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Incident Medical and Dental:

Emergency transportation available
First Aid Kid observed

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is in place.

Residents with Special Health Needs:

Needs and Services Plan and Appraisals are on file.
Currently (1) resident receiving hospice services. Hospice care plan observed.
Orders for bed rails on file

The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809-D). Exit interview conducted and a copy of this report and appeal rights were provided and discussed.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3