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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603200
Report Date: 08/19/2023
Date Signed: 08/19/2023 03:34:34 PM


Document Has Been Signed on 08/19/2023 03:34 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:PRISTINE GUEST HOMEFACILITY NUMBER:
198603200
ADMINISTRATOR:BUAN, ALAN ROBERTFACILITY TYPE:
740
ADDRESS:1026 HEDGEPATH AVETELEPHONE:
6262952479
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY:6CENSUS: 6DATE:
08/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Staff S1TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/19/2023. LPA was met by Staff#1 (S1) and explained the purpose of the visit. Administrator Alan Buan and Staff #3 (S3) later arrived to the facility to assist in tour. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is currently approved for three (3) hospice care residents. LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), and Resident Roster (LIC 9020).
LPA OBSERVATIONS: Tour was led by S3. The facility is a single-story building located in a residential area with four (4) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, kitchen, dining area, living room, laundry room, front yard, backyard, and attached garage. Facility has two (2) live in care givers and one (1) registered nurse/nurse practitioner (RN/NP) that provides care to residents on a regular basis.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed a sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to six (6) out of six (6) residents in care. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguisher in this area. Water temperature in kitchen sink was measured at 117.6 degrees F.

Dining area/Living room: Living room was observed plenty of seating and lighting. LPA Ramirez observed two (2) residents sitting in living room area and dining area during visit.

Linen Closet: Contained plenty linens, towels, and hygiene products. LPA observed thermostat in this nearby area to read 76 degrees F.

Resident Rooms 1 - 4: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed required auditory devices on exits. LPA Ramirez observed signs outside residents’ rooms cautioning “Oxygen in use.”

see 809-C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2023
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: PRISTINE GUEST HOME
FACILITY NUMBER: 198603200
VISIT DATE: 08/19/2023
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Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 109.4 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 water temperature was measured at 116.7 degrees F. LPA Ramirez observed signs promoting hand washing in bathroom. Grab bars and non-slip mats were observed in both bathroom bathing areas.

Centrally Stored Medications: LPA Ramirez observed locked closet near kitchen and living room area to inaccessible to six (6) out of six (6) residents in care.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed.

Emergency Drills: Last documented fire drill was conducted on 7/1/23 at 10:15 am.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan. LPA Ramirez observed smoke detectors to be operational during visit.

Staff Personnel Files: LPA Ramirez reviewed five (5) personnel files that were maintained at the facility. Five (5) out of the five (5) personnel files reviewed did not document the required 20 annual training hours. Per staff S3, facility was in the process of conducting training. LPA Ramirez did observe prior annual training in 2022 and 2021 being conducted during the late days on JUNE AND AUGUST. LPA Ramirez issued Technical Violation. Licensee will submit proof of staff annual training based on title 22 regulations and email such proof to LPA Ramirez no later than 9/2/23.

Resident Files: LPA Ramirez reviewed six (6) resident files.

Liability Insurance & Infection Control Plan: Licensee will submit copy of Liability Insurance and Infection Control Plan by 9/02/23. LPA Ramirez issued Technical Violation for proof of Liability Insuramce.

No deficiencies are being cited today. Exit interview was conducted S2 and a copy of this report, LIC 9102 and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023
LIC809 (FAS) - (06/04)
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