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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603124
Report Date: 09/02/2022
Date Signed: 09/02/2022 02:50:00 PM


Document Has Been Signed on 09/02/2022 02:50 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:LA POSADA IN GLENDORAFACILITY NUMBER:
198603124
ADMINISTRATOR:DIAZ, RAFAELFACILITY TYPE:
740
ADDRESS:1239 S SUNFLOWER AVETELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 6DATE:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Santos Valencia- CaregiverTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced required annual inspection at the facility. LPA Maldonado met with caregiver Santos Valencia and explained the purpose for the visit. Administrator Rafael Diaz was called and was also explained to purpose for the visit. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with caregiver Santos, observed the food and PPE supplies, and reviewed COVID-19 procedures, resident's medications and files, and staff files. The facility has submitted a mitigation plan and approved on 04/20/2021.

The facility is a home located in a residential area. It is licensed to serve six (6) non-ambulatory residents, of ages 60 and over, of which one (1) may be bedridden. The facility has dementia care for residents and an approved hospice waiver for 2 residents. The facility has secured perimeters in the form of a motorized gate in the front to prevent residents from leaving the property. The home consists of five (5) resident bedrooms, one (1) which is a shared room, 2 bathrooms, a kitchen, dining room, office area, living room, shaded patio, and attached garage. During the visit, 6 residents in care were observed and 2 staff working. LPA toured the facility with caregiver Santos and observed the facility's food supply to have a variety of nutritious foods and was more than the required 2 day perishables, 7 day non-perishables, and emergency supplies.

At 9:37 a.m., LPA observed a kitchen knife on top of the counter next to the kitchen sink. The staff stated they just finished preparing breakfast for the residents and put the knife away immediately.

All resident bedrooms were observed to have the required bed linens, furniture, and sufficient lighting. Bathroom (RR)# 1 and # 2 had a working toilet, wash basin, and shower that accommodates non-ambulatory residents.

At 9:45 a.m., room# 3 was observed to have cleaning supplies left out on the floor near the entrance.
(Report Continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
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 6


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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124
VISIT DATE: 09/02/2022
NARRATIVE
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At 9:56 a.m., the water temperature was tested and measured at 144.2*F in RR#1 and 141.4*F in RR#2. The RR's were also observed to be missing the required non-skid mats. Staff state regular bath towels are used in lieu of non-skid mats/strips as the facility is not equipped with any mats.

All sinks were observed to be fully stocked with hand soap and paper towels for hand washing. Sufficient PPE was observed in the garage and in residents rooms. Laundry appliances were located in the garage and were observed to be operating and in good repair. All walkways and entrances/exits were observed to be free of debris and hazards. A fire extinguisher was observed in the kitchen to be fully charged. The smoke/carbon monoxide detectors were tested during the visit and were observed to be operational.

At 10:26 a.m., LPA reviewed (5) of (6) resident files to confirm emergency contacts are updated. LPA also reviewed (2) staff files to confirm health screenings and fingerprint clearances. LPA reviewed (6) residents' medications. (4) of (6) resident files did not have complete files or updated emergency contacts. (1) of (6) resident files were not available to review at the facility, during the time of the visit. (1) of (2) staff files did not have health screenings or fingerprint clearance. No written orders were found for (2) residents' medications, and (3) residents had medications in their medication box that are not currently listed on their medication list. (1) resident with dementia did not have an updated Physician's Report.

Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D.

Additionally, immediate civil penalties in the amount of $500 will be issued today.

An exit interview was conducted with administrator Rafael Diaz over the phone and a copy of this report and appeal rights were provided to staff Santos Valencia.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/02/2022 02:50 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review… shall prior to working… in a licensed facility: (2) Request a transfer of a criminal record clearance…
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 of 2 staff having a criminal background clearance, but not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2022
Plan of Correction
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The licensee will associate the staff in question via Guardian and provide a copy of the facility association list as proof of association, via email to LPA by the POC due date: 09/03/22.
Type A
Section Cited
CCR
87303(e)(2)&(5)
87303 Maintenance and Operation
(e) Water supplies… shall be maintained as follows: (2) Faucets used by residents for personal care… shall deliver hot water. Hot water temperature controls shall be maintained… to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
(5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in 2 of 2 bathroom sinks which water temperature measured at 144.2*F and 141.4*F. LPA also observed that 2 of 2 showers were missing non-skid mats. Staff explained none were available at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2022
Plan of Correction
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Licensee will lower the temperature on the water heater and measure it to ensure it measures within 105*F-120*F to be in compliance. A log of the water temperature will also be completed and provided to LPA for the following 5 days to ensure the water temperature is maintained. Non-skid mats/strips will be purchased and a picture of them installed, along with a copy of the receipts will be provided to LPA by the POC due date: 09/03/22.

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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 09/02/2022 02:50 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)&(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives… that could constitute a danger to the resident(s). (2) … toxic substances such as… cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 kitchen knife left out on top of the counter next to the kitchen sink, accessilbe to persons in care. And floor cleaning soution was left unattended in one of the resident's rooms, accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2022
Plan of Correction
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The staff that assisted with the visit immediately put away the knife and the cleaning supplies, making them inaccessible to persons in care. This deificiency has been cleared.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 09/02/2022 02:50 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia
(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 resident with dementia did not have an updated medical assessment or reappraisal (last one was 08/26/19) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee has agreed to have a medical assessment and reappraisal completed for dementia residents and have it available in their file. A copy of the updated records will be emailed to LPA by the POC due date: 09/16/22.
Type B
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 residents not having a written order from a physician in their file for the medications they are currently taking, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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The licensee has agreed to contact the resident's primary care physician's to obtain the written orders for the medications the residents are currently taking. A copy of the written orders will be emailed to LPA by the POC due date: 09/16/22.

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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/02/2022 02:50 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 of 6 resident's files were not readily available at the facility for LPA to review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee has agreed to bring the resident's file to the facility and maintain it there. A copy of the resident's complete file will also be emailed to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6