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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603012
Report Date: 01/30/2024
Date Signed: 01/30/2024 02:03:11 PM


Document Has Been Signed on 01/30/2024 02:03 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:INSPIRED ELDERLY CARE LIVINGFACILITY NUMBER:
198603012
ADMINISTRATOR:GALLEGOS, LAURIEFACILITY TYPE:
740
ADDRESS:1438 E PORTNER STREETTELEPHONE:
(909) 240-1321
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY:6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Laurie Gallegos, AdministratorTIME COMPLETED:
02:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza 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 caregiver Lilibeth Alcala. Administrator Laurie Gallegos arrived shortly after. The facility serves residents ages 59 and older. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A Dementia waiver and hospice waiver for six (6) is in place.
  • A fire clearance for 6 non-ambulatory adults 60 and over.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 2/1/2024.
  • A surety bond is not applicable. Facility does not handle resident's money.


"Narrative continues next page.****
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSPIRED ELDERLY CARE LIVING
FACILITY NUMBER: 198603012
VISIT DATE: 01/30/2024
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood. It consists of 5 bedrooms; 4 for residents [2 private & 2 shared) and 1 staff bedroom in room #5, 2 1/2 bathrooms, living room, dining room, game room, kitchen, outdoor patio area, laundry room in bathroom, and a 2 car attached garage.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There is an inoperable small water fountain and jacuzzi in the backyard. The backyard cement walkway is cracked and lifted posing a tripping hazard. A citation was issued.
  • The facility has two (2) fully charged fire extinguisher and a pull alarm
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:
  • A total of 4 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expires 9/5/2024.
  • Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training were verified.

Resident Records/Incident Reports:
  • A total of six (6) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
  • Indoor and outdoor activities are scheduled at least 3-4 times a week.
  • The facility does not have a Resident Council.

***Narrative continues next page.***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSPIRED ELDERLY CARE LIVING
FACILITY NUMBER: 198603012
VISIT DATE: 01/30/2024
NARRATIVE
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Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are in place.

Incident Medical and Dental:
  • Centrally stored resident medications were observed to have a 30-day supply of medications.
  • Resident (R1) had 1 medication and 2 supplement medications in an unlocked drawer in the room. The supplements do not have physician orders. Citation was issued.
  • Medical and dental transportation is provided by family members.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last emergency disaster drill was conducted on 11/16/2023.

Residents with Special Health Needs:
  • One (1) resident is receiving home health services and one (1) resident is enrolled in hospice care.
  • Postural support physician orders are on file.
  • Half bed rails for mobility assistance were observed in resident beds. A full bed rail was also observed for the resident enrolled in hospice services.
  • Individual Service Plans and Appraisals were not observed in resident files.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Laurie Gallegos. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/30/2024 02:03 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: INSPIRED ELDERLY CARE LIVING
FACILITY NUMBER: 198603012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that resident (R1) Clotrimazole topical cream in an unlocked drawer & R2 had 7 Rx medication bottles in unlocked drawer, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agrees to submit a written plan of correction that states how the deficiency was corrected and shall conduct staff training in regulationTitle 22 Incidental Medical and Dental Care Services. The medications were removed during the visit. Submit POC by tomorrow.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
Deficient Practice Statement
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Based on physical plant inspection, the licensee did not comply with the section cited above in that resident Dementia resident (R1) had cranberry extract 500 mg supplement, and homeopathic Frankincense Myrrh rubbing oil in an unlocked drawer without a physician order, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator shall obtain a physician order for the supplement medicine items noted above, and conduct staff training. Administrator removed the items from the room. Submit proof of correction by tomorrow.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 01/30/2024 02:03 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: INSPIRED ELDERLY CARE LIVING
FACILITY NUMBER: 198603012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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:
Deficient Practice Statement
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Based on physical plant observation, the licensee did not comply with the section cited above in that the backyard cement walkway is cracked and lifted posing a tripping hazard and stovetop burners are being ignited with a candle lighter, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee/Administrator agreed to repair the cracked/lifted cement section in the walkway, and repair/replace the stovetop. Submit picture proof evidence 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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