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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603225
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:28:48 PM


Document Has Been Signed on 08/09/2024 04:28 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 LIVINGFACILITY NUMBER:
198603225
ADMINISTRATOR:KLEIN, KATHRYNFACILITY TYPE:
740
ADDRESS:1216 ROYAL OAKS DRIVETELEPHONE:
(626) 408-7802
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY:28CENSUS: 20DATE:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sister Marie Estelle OCD - Chief Executive OfficerTIME COMPLETED:
04:22 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Sister Cecilia Marie, Resident Care Assistant and Miguel Angel Gonzalez, Maintenance Technician/Supervisor and explained the purpose of the visit. Shortly after, Sister Marie Estelle OCD, Chief Executive Officer assisted LPA with the inspection. There are currently (20) residents, 60 years and older residing in the facility, of which (1) is under hospice care and (0) bedridden resident. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date.
Operational Requirements: The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (12) is approved. A fire clearance is in place. Liability Insurance is valid and expires on 06/15/2025. Last fire drill was last conducted on 04/29/2024.
Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: lobby, dining room, living room, kitchen, office, den, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and (10) resident rooms. Second floor:activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and (11) resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in (6) random resident rooms (Rooms #D3, #D5, #D10, #D23, #D28 and #D31) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has eight (8) fully charged fire extinguishers, last serviced on 05/10/2024. *****CONTINUED ON LIC809-C*****
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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: 08/09/2024
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Staffing: A total of (43) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed (5) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records-Training: (5) staff files reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator on file is current, certificate is valid and will expire on 12/23/2024.
Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and meet on a monthly basis.
Food Service: Sufficient food supply is stored in the kitchen consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for residents to use and to store their meals. Pesticides and cleaning supplies are kept away from the food preparation areas.
Incident Medical and Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored. A complete first aid kit is maintained. Medical and dental transportation is provided.
Resident Records/Incident Reports: A total of (5) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, and Medication Records.
Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place.
Residents with Special Health Needs: Currently, (1) resident is under hospice care, (0) bedridden, (0) resident receiving home health services and (2) residents using oxygen have "No smoking in use" signs posted.

Inspection Tool was completed and no Title 22 deficiencies are being cited on todays' visit.
Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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