198603124-9-16-2023-28-AS-KRAZ-CVQUTF-20230916155151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603124
Report Date: 09/16/2023
Date Signed: 09/16/2023 03:52:01 PM

Document Has Been Signed on 09/16/2023 03:52 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:	LA POSADA IN GLENDORA		FACILITY NUMBER:	198603124
ADMINISTRATOR:	DIAZ, RAFAEL		FACILITY TYPE:	740
ADDRESS:	1239 S SUNFLOWER AVE		TELEPHONE:	(562) 774-7167
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	RAFAEL DIAZ		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 09/16/2023. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents and is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has dementia care for residents and an approved hospice waiver for two (2) residents. The facility has secured perimeters in the form of a motorized gate in the front to prevent residents from leaving the property.

LPA OBSERVATIONS: Tour began at 10:10 am and was led by S1. The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in garage, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in garage area to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 119.7 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area. LPA Ramirez observed three (3) out of five (5) residents in care sitting and resting in living room during visit.

Linen Closet: Contained plenty linens, towels, and hygiene products.

SEE 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

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: LA POSADA IN GLENDORA	FACILITY NUMBER: 198603124
	VISIT DATE: 09/16/2023

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Resident Rooms 1 - 5: LPA Ramirez observed all five (5) out of the five (5) resident bedrooms to contain required furnishings, lighting and linens. Resident room #4 is a shared bedroom. Resident bedroom #5 is currently not occupied. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. All resident rooms appeared to be clean.

Bathrooms: Signs promoting hand washing were observed. Water temperature in resident shared bathroom#1 was measured at 105.4 degrees F which is in the required 105 – 120 degrees F. Private Bathroom #2 located in resident bedroom #4 was observed to be clean and water temperature was measured at 109.2 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms. LPA observed containers without lids that store solid waste. LPA Ramirez will issue Technical Violation.

Centrally Stored Medications: LPA observed cabinet located in hallway closet and was observed to be locked and inaccessible to residents in care.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s Diaz certificate with an expiration date of 10/17/2023. LPA Ramirez will issue Technical Violation for three (3) out of the three (3) staff missing renewed CPR/FIRST AID training from staff files.

Resident Files: Five (5) resident files were reviewed. LPA Ramirez will issue Technical Violation for R1 and R2 missing original signed and dated Admissions agreement.

Liability Insurance & Infection Control Plan: LPA Ramires obtained current liability insurance. Licensee will email updated infection control plan within 7 business days to LPA Ramirez.

No deficiencies are being cited. Exit interview was conducted with staff #2 (S2) and a copy of this report, LIC 9102s and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

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