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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603225
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:25:58 PM


Document Has Been Signed on 02/15/2024 02:25 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: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: 21DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrative Assistant Nathan NemethTIME COMPLETED:
02:40 PM
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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrative Assistant Nathan Nemeth. The following (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed

Physical Plant/Environment Safety:
  • The facility is a two story building. 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.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible. There are no open bodies of water
  • Water temperature readings measured within title 22 regulations.

Operational Requirements:
  • A current Plan of Operation observed.
  • The facility has an approved fire clearance for a capacity up to twenty-eight (28) Non-ambulatory residents of which ip to eight (8) may be bedridden. The Licensee has a Hospice Waiver for 12 residents. Facility is operating within the scope of its fire clearance

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed.
Continued on LIC 809-C
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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
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: 02/15/2024
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Personnel Records - Staff Training:
  • Administrator on file is current . Certificate is active
  • Staff have criminal background clearances.
  • Five(5) staff files were reviewed. Required documents and training's observed

Staffing:
  • Sufficient staff observed during visit. At least one on each shift has CPR training
  • Administrator on schedule sufficient amount of time
  • Signal system in resident rooms were observed and operational.

Resident Records - Incident Reports:
  • A total of six (6) resident files were reviewed. Required documents observed on file
Resident Rights - Information
  • Required postings observed


Food Service:
  • Sanitation practices and kitchen cleanliness was observed.
  • Kitchen has utensils for residents to use and to store their meals
  • No cleaning supplies stored near food
  • Sufficient supply of perishables and non perishables was observed

Incident Medical and Dental:
  • First Aid Kid observed
  • (6) of (6) Resident medications reviewed. Medications are centrally stored.

Disaster Preparedness:
  • Emergency and Disaster Plan observed
  • Evacuation Chairs observed at each stairwell

Residents with Special Health Needs:
  • Currently (0) residents receiving hospice services.

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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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