198603302-2-1-2024-28-AS-CDCN-D22VDW-20240201152126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603302
Report Date: 02/01/2024
Date Signed: 02/01/2024 03:21:59 PM

Document Has Been Signed on 02/01/2024 03:21 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:	SUMMIT VIEW HOME CARE		FACILITY NUMBER:	198603302
ADMINISTRATOR:	CASTRO, SILVIA		FACILITY TYPE:	740
ADDRESS:	107 CLEARVIEW CREST DR		TELEPHONE:	(909) 396-7839
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	02/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:41 AM
MET WITH:	Theresa Kuwashima, staff		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 2/1/24. LPA arrived unannounced and met with Staff, Theresa Kuwashima. The purpose of the visit was explained. Administrator, Silvia Castro, arrived shortly after to assist with the visit. The facility is licensed for 6 non-ambulatory residents, ages 60 and over, of which 1 may be bedridden. There is a hospice waiver approved for 3 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tool to inspect the facility and the following were observed: Infection Control: The facility staff are performing hand hygiene and wearing gloves when necessary to assist residents. Staff are cleaning and disinfecting daily and following the infection control plan. Administrator provides annual training on infection control. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 5 non-ambulatory and 1 ambulatory resident residing at the facility. The facility maintains sufficient liability insurance to cover injury to residents and guests. Physical Plant & Environment Safety: The facility is a one-story house that consists of 4 resident bedrooms, 1 communal bathroom, 1 staff room with private bathroom, living room, kitchen, dining area, laundry area, and attached garage. Cleaning supplies are locked in the closet and inaccessible to residents. The facility has smoke detectors in each room and 1 carbon monoxide detector in the hallway by the front door. The fireplace is adequately screened. There are no pools or bodies of water on the premises and no items obstructing the walkway. Staffing: There is sufficient staffing at the facility. Staff employed have fingerprint clearance and associated to the facility.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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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Document Has Been Signed on 02/01/2024 03:21 PM - It Cannot Be Edited

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: SUMMIT VIEW HOME CARE	FACILITY NUMBER: 198603302
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff files which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	The licensee shall ensure that Staff #2 and all new employee have the TB test result and/or chest x-ray no more than 6 months prior to or 7 days after employment. A statement acknowledging this regulation along with proof of Staff #2's TB test result shall be submitted to LPA by 2/15/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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: SUMMIT VIEW HOME CARE	FACILITY NUMBER: 198603302
	VISIT DATE: 02/01/2024

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 3 staff files. They have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff #2 did not have the TB test result nor chest x-ray on file.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Consent forms, Resident rights, Safeguards for Property/Valuables form.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability. Staff encourage residents to participate in activities.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The kitchen is clean and free of rodents or insects.
Incidental Medical & Dental: The medications are centrally stored and in their original bubble packs. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed all 6 residents' medications and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. They conduct different types of disaster drills and are documented with the date, time, and participants.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff receive the appropriate number of hours annually to care for residents with dementia.

LPA interviewed 2 Staff and a resident during the visit. A deficiency is issued on the LIC809D. An exit interview was held. A copy of this report and appeal rights were given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC809 (FAS) - (06/04)

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