198603225-2-17-2023-28-AS-ALOZ-CP5RGH-20230217120045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603225
Report Date: 02/17/2023
Date Signed: 02/17/2023 12:01:09 PM

Document Has Been Signed on 02/17/2023 12:01 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:	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: 14	DATE:	02/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Sister Magdalene Grace		TIME COMPLETED:	12:12 PM

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Licensing Program Analyst (LPA) Alberto Lopez arrived at this facility unannounced to conduct an annual inspection visit. Upon arrival, LPA met with Sister Magdalene Grace 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 11 resident rooms.

LPA toured a randomly selected resident's rooms on each floor. Resident rooms were sanitary and had been 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 hot water temperature was tested throughout the facility and measured within Title 22 Regulation guidelines.

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. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance.

(CONTINUED ON 809C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

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: CRISTO REY COTTAGE ASSISTED LIVING	FACILITY NUMBER: 198603225
	VISIT DATE: 02/17/2023

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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 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC809 (FAS) - (06/04)

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