198603124-8-30-2024-28-AS-BTAO-D8MTSM-20240830145921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603124
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:59:32 PM

Document Has Been Signed on 08/30/2024 02:59 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 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: 6	DATE:	08/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Paula Mera, administrator		TIME COMPLETED:	03:00 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) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Paula Mera, who assisted with the visit. The facility is licensed to serve residents ages 60 and above, with a capacity of six (6) residents including six (6) non-ambulatory of which one (1) may be bedridden. The facility had dementia care program. Annual fees were current. Hospice waivers were approved for two (2) residents. Currently, there are three (3) hospice residents residing at the facility. For today’s inspection visit, the CARE tool was used; a physical plant was conducted; food supply was reviewed; staff/residents were interviewed; and staff/residents’ facility records along with medications were reviewed. Administrator certificate is current with expiration date on 11/22/24. The facility was located in a residential neighborhood. The facility consisted of five (5) resident bedrooms, one (1) which is a shared room, two (2) bathrooms, a kitchen, dining room, office area, living room, shaded patio, and attached garage. The facility had secured perimeters with a motorized gate in the front to prevent residents from leaving the property. All the rooms were furnished with appropriate furniture for residents’ comfort. (-continued in LIC 809C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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: LA POSADA IN GLENDORA	FACILITY NUMBER: 198603124
	VISIT DATE: 08/30/2024

NARRATIVE

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The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 119.8 degrees Fahrenheit. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supplies of perishable and nonperishable foods were observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged. Medication, residents’/ staff’s records were centrally stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to residents.

Deficiencies were observed and cited per California Code of Regulations, Title 22, in LIC 809 D. An exit interview was conducted. This report and Appeal rights were discussed and provided to administrator Paula.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 02:59 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: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

Capacity and Ambulatory Status 87204(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met as evidenced by: The facility has approved two (2) hospice waivers on file but the Licensee retained three (3) hospice residents at the facility since 8/13/24.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a request for hospice waiver increase to a total of three (3) or apply an exception for the one individual who admitted to hospice on 8/13/24 by the 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: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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