198603163-10-31-2023-28-AS-CWOG-CX5U8A-20231031152112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603163
Report Date: 10/31/2023
Date Signed: 10/31/2023 03:22:25 PM

Document Has Been Signed on 10/31/2023 03:22 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:	DWIGHT DUNAGAN		FACILITY TYPE:	740
ADDRESS:	4825 EARLE AVE		TELEPHONE:	(626) 287-0438
CITY:	ROSEMEAD	STATE: CA	ZIP CODE:	91770
CAPACITY:	85	CENSUS: 37	DATE:	10/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dwight Dunagan		TIME COMPLETED:	03:40 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) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Dwight Dunagan and assisted LPA with the visit. The facility is licensed to RCFE/Dementia for age range 60 and over. Approved for 85 non-ambulatory, of which 9 may be bedridden, approved hospice waiver for 20. Currently, there's two residents on home health, six residents on hospice but no bed ridden residents. On today's date, LPA inspected the following domains which include: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Record-Training, Resident Records/Incident Reports, Resident's Right, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness and Resident with Special Health Needs 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents; of which 9 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility is consisted of a 5 floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor. LPA inspected Room#106, #116, #212, #205, #303, #301, #412, #414 and the rooms are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: CALIFORNIA MISSION INN - ROSE MANOR	FACILITY NUMBER: 198603163
	VISIT DATE: 10/31/2023

NARRATIVE

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Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature were tested between 105 and 112.6 degrees F which is within the Title 22 regulation. LPA also inspected the carbon monoxide detectors in the facility and they are working properly. The facility has a telephone service on the premises.

4. Staffing: The facility has sufficient staffing to provide care and supervision to residents

5. Personnel Record-Training : All the staff are over 18 years old and they are fingerprint cleared and associated with the facility. LPA inspected four staff files and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Dwight Dunagan and his administrator certificate expiration date 7/11/2024.

6. Resident Record-Incident Reports: LPA inspected 4 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

7. Resident's Right: LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician.

8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for the facility. The facility does not have a resident council but regular town hall meeting.

9. Food Service: Currently the facility has 3 resident is on a modified diet with physician order in file. The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. Sanitation practices and kitchen cleanliness was observed.

10. Incidental Medical and Dental: LPA inspected four (4) residents medication and the medication are centrally stored and locked in the Wellness Center room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide transportation to residents' medical and dental appointments.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: 10/31/2023

NARRATIVE

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11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 10/20/22. The last fire drill was conducted on 9/22/23 and the last disaster drill was conducted on 6/28/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training.

12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are six resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice.

No deficiencies were observed during the visit.

Exit Interview Conducted and a copy of the report was provided to Administrator Dwight Dunagan.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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