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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 10/07/2021
Date Signed: 10/07/2021 04:24:47 PM

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:CALIFORNIA MISSION INN - ROSE MANORFACILITY NUMBER:
198603163
ADMINISTRATOR:TYLER CHENEYFACILITY TYPE:
740
ADDRESS:4825 EARLE AVETELEPHONE:
(626) 287-0438
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:85CENSUS: 43DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Tyler Cheney, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analysts (LPA) Galarza and Jewel Baptiste conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Tyler Cheney and Wellness Director Ruby Magao and explained the purpose of the visit. The facility is a 5 story story building located in a residential neighborhood that is licensed for 85 adults 60 and over approved for 85 non-ambulatory, of which 9 may be bedridden. The facility has a hospice waiver for 20. The facility consists of 69 rooms, activity room, dining room, kitchen, Wellness office, laundry room, and an outdoor water fountain. The last fire drill was conducted on 9/3/2021.

The following were observed/inspected:
  • The interior and exterior physical plant was inspected. Twenty nine (29) rooms were inspected.
  • COVID-19 Infection Control Practices and signs were observed in the entrance, some common areas hallways, but not in the public bathrooms and resident bathrooms.
  • Signs are not posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart.
  • Each client's room is designated as a COVID-19 solation room if needed.
  • All staff were observed wearing mask.
  • Six (6) centrally stored resident medication records were reviewed. Medication errors were observed.
  • The residents were observed wearing masks.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A posted Emergency Disaster Plan was observed.
  • Facility has sufficient supply of Personal Protective Equipment (PPEs).
  • Resident's physician reports were reviewed during today's visit.


Deficiencies were cited. See LIC 809D.

Exit interview was conducted with Administrator Tyler Cheney and Wellness Director Ruby Magao. A copy of the report was provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
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 2
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: CALIFORNIA MISSION INN - ROSE MANOR
FACILITY NUMBER: 198603163
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.50(a)(3)
Suspension and Revocation
(a)(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

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 signs are not posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. The public bathrooms, resident bathrooms, and common area hallways did not have COVID-19 infection control signs. 15 out of 29 resident rooms inspected did not have either hand sanitizer or hand soap in the rooms. In addition, the latest Provider Information Notice (PIN) 21-44 was not posted where persons in care can easily access it and distribute the PIN Summary for Persons in Care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2021
Plan of Correction
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Administrator agreed to post infection control signs in all bathrooms, common area hallways, as well as ensure that hand sanitizer and soap are available for all residents in care. The latest PINs shall be posted in an easily accessible location.

Submit a written statement stating how the deficiency was corrected. Attach picture proof of common area/public bathroom postings.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that medication errors were observed for residents (R1- R4). Resident (R1 & R2) had medications in the room, but per Physician's Report they are not able to administer medications. Resident (R3) was missing Melatonin tablet 10mg. Resident (R4) was observed to have medication Aquaphor ointment in the room; however per physician report cannot administer own medications.

] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2021
Plan of Correction
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Administrator agreed to submit a written plan of correction by tomorrow. All med-tech and direct care staff will be provided medication administration training.

This training shall be provided by a pharmacy and/or registered nurse.
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: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021
LIC809 (FAS) - (06/04)
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