198603163-10-3-2024-28-AS-KRAZ-D9PVQE-20241003163812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:38:54 PM

Document Has Been Signed on 10/03/2024 04:38 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:	CALIFORNIA MISSION INN - ROSE MANOR		FACILITY NUMBER:	198603163
ADMINISTRATOR:	JARED GREEN		FACILITY TYPE:	740
ADDRESS:	4825 EARLE AVE		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 40	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Wellness Coordinator Jessica Estrada		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Jessica Estrada (Wellness Coordinator) and discussed the purpose of today’s visit. Maintenance Director Andy Mendoza arrived shortly after to assist with the inspection. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#216. Staff responded 5 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. LPA Ramirez observed video surveillance in rooms# 211 & 216. Video surveillance was placed at the request of the residents and family. LPA Ramirez will issue Technical Violation based on this observation.

Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets.

See 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CALIFORNIA MISSION INN - ROSE MANOR	FACILITY NUMBER: 198603163
	VISIT DATE: 10/03/2024

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Planned Activities: LPA Ramirez observed an activities calendar for October of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 09/17/24. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility.

Residents with Special Needs: Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible.
Operational Requirements: The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training only for four (4) out of the four (4) staff files requested. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez was unable to review the following: CPR and First Aid, TB testing results, Health screening, fingerprint clearance, and job application.

Staffing: Administrator Certificate for Jared Green and it expires 04/14/2026.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

No deficiencies were observed during this inspection. Exit interview was conducted with Jared Green and a copy of this report, LIC 9120 and appeals rights was provided via email.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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