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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603200
Report Date: 09/10/2021
Date Signed: 09/10/2021 07:53:53 PM

Document Has Been Signed on 09/10/2021 07:53 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:PRISTINE GUEST HOMEFACILITY NUMBER:
198603200
ADMINISTRATOR:BUAN, ALAN ROBERTFACILITY TYPE:
740
ADDRESS:1026 HEDGEPATH AVETELEPHONE:
(626) 295-2479
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 4DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alan Buan TIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez conducted an annual required visit. LPA's met with caregiver Evangeline Mendoza and explained the reason for the visit. Shortly after, the administrator Alan Buan arrived and assisted with the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility submitted the mitigation plan and was approved on 4/24/21

The facility is a single story house located in the neighborhood. The facility consists of 4 resident bedrooms, two bathrooms, kitchen, dining area, living room, medication/storage room and attached garage. Each bedroom has required furniture, sufficient storage space and equipment. Bedroom#1 and #2 have single bed. Bedroom#3 and #4 have two beds. Each resident bedroom has all required linen including mattress pad. All 2 bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. While touring the dining room/kitchen area, LPA observed ample food supply of two (2) days of perishables and seven (7) days of non-perishables. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The hot water temperature measured at the two bathrooms between 115.4 degrees and 123.6 degrees F which is beyond the required 105 - 120 degrees. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area. Carbon Monoxide and smoke alarms were tested and were operational.

LPA's reviewed 4 resident files to confirm emergency contact is updated. LPA's also reviewed staff files to confirm health screenings and fingerprint clearances. LPA's reviewed 4 residents' medications. All four residents' PRN medication are missing and there's no discontinuation order. Staff reported resident does not take the PRN medication for a long time.

The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to house manager via email.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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Document Has Been Signed on 09/10/2021 07:53 PM - It Cannot Be Edited


Created By: Christine Wong On 09/10/2021 at 09:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRISTINE GUEST HOME
FACILITY NUMBER: 198603200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the hot water temperature tested at the bathroom#1 was 123.6 which is beyond the required 105-120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2021
Plan of Correction
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The administrator will ensure the hot water temperature tested between 105-120 degrees F at all times. The administrator will fix the hot water temperature immediately and send the hot water log for 7 days to LPA by 09/17/21
Type A
Section Cited
CCR
87645(c)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA reviewed all four residents PRN mediation were misisng in the facility without any disontinuation order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2021
Plan of Correction
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The administrator will ensure Once ordered by the physician the medication is given according to the physician's directions. The administrator will contact the doctor right away to discontinue the medication or re-order the medication and send the discontinaution order or medication to LPA by POC due date
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021


LIC809 (FAS) - (06/04)
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