198603225-10-26-2021-28-AS-NMAN-C86Q9B-20211026115804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603225
Report Date: 10/26/2021
Date Signed: 10/26/2021 11:58:17 AM

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:	CRISTO REY COTTAGE ASSISTED LIVING		FACILITY NUMBER:	198603225
ADMINISTRATOR:	MORLOK, NICOLE M		FACILITY TYPE:	740
ADDRESS:	1216 ROYAL OAKS DRIVE		TELEPHONE:	(626) 408-7802
CITY:	MONROVIA	STATE: CA	ZIP CODE:	91016
CAPACITY:	28	CENSUS: 22	DATE:	10/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator: Aracely Aguilera		TIME COMPLETED:	12:00 PM

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On 10/2621 at 9:00 AM, Licensing Program Analysts (LPA) Nune Margaryan arrived at this facility unannounced to conduct an annual inspection visit. Upon arrival, LPA met with Administrator Aracely Aguilera who assisted with the visit. The purpose of visit was explained.
The facility has an approved fire clearance for twenty (20) Non-ambulatory and eight (8) Bedridden residents. The Licensee has a Hospice Waiver for 12 residents. Facility does not have Dementia Care in their plan of operation and not accepting residents diagnosed with dementia. This is a two story building located in a residential neighborhood. There are 22 resident bedrooms of which 6 are double occupancy.
There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. LPA toured the physical plant areas inside and outside to ensure compliance with Title 22 regulations. LPA also conducted the infection control domain tool.

The first floor consists of a dining room, living room, kitchen, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and 10 resident rooms. The second floor consist of an activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and 12 resident rooms.

LPA toured a randomly selected resident's rooms on each floor. Resident rooms were sanitary and had furnished appropriately. Each resident room has their own bathroom. The bathrooms were observed to be clean and operational w/grab bars. Resident rooms are equipped with signal systems. There is a signal system located by the resident bed and inside the bathroom. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines.

Continued 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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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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: CRISTO REY COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198603225
	VISIT DATE: 10/26/2021

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The facility has central air and heating accommodations. There is a functioning telephone on the premises and there is emergency lighting, such as flashlights and night lights. The fire extinguishers and carbon monoxide detectors were observed to be fully charged and in compliance. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The outdoor area was enclosed. LPA observed a water fountain in front of the facility.

The kitchen was observed for the ability to prepare and serve food. Appliances in the kitchen were clean and all appeared functional. During today's visit, LPA observed an appropriate food supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. All sharp objects and knives are stored in the kitchen cabinet making it inaccessible to residents. All chemicals and cleaning solutions are observed to be locked and inaccessible to the residents.

The facility has central air and heating accommodations. The facility has a fireplace located on both floors of the building (located in the living rooms) but the fireplace does not produce heat and is only for display.

Medications and First Aid Kit are centrally stored in the locked medications rooms located on each floor. First aid kit is fully stocked with a manual.

Per California Code of Regulations, Title 22, deficiencies were not observed during the visit. Exit interview conducted and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

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