198603317-5-23-2023-28-AS-CWOG-CS4RJ9-20230523130334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:05:17 PM

Document Has Been Signed on 05/23/2023 01:05 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:	VINE RESIDENCE		FACILITY NUMBER:	198603317
ADMINISTRATOR:	LOPEZ, LORRAINE		FACILITY TYPE:	740
ADDRESS:	1405 E. VINE AVE		TELEPHONE:	(626) 890-7634
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91791
CAPACITY:	6	CENSUS: 6	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Lorraine Lopez		TIME COMPLETED:	01:20 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) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Caregiver Sandra Portillo Alvarez. Administrator, Lorraine Lopez, arrived shortly thereafter to assist. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. 6 Ambulatory, of which 5 may be non-ambulatory and 1 may be bedridden. Hospice Waiver for 6 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: All staff have the updated physician report with TB Test result. The facility has an emergency blinder for residents including all their physician phone number, current medication..etc. The facility also has a blinder with all the emergency agency phone number. The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting once a day and more often for high touched surfaces. Staff would also conduct the deep cleaning once a week. Facility has sufficient PPE supplies and has an Infection Control Plan. 2. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 6 residents in the facility and 5 residents are on hospice which 2 are ambulatory and 4 are non-ambulatory. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 3. Physical Plant/Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes break room, dining room, kitchen, TV room, 6 bedrooms and 3 bathrooms and an attached garage. The hot water temperature in 3 bathrooms were tested between 109.2 and 120 degrees F. which are within the Title 22 regulation. (See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: VINE RESIDENCE	FACILITY NUMBER: 198603317
	VISIT DATE: 05/23/2023

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
26
27
28
29
30
31
32

LPA inspected the carbon monoxide detectors and smoke detectors and they are all located in each bedroom and common area. They are all interconnected and they are working probably. All the sharp knives and utensils are locked in the kitchen drawer. All the cleaning supplies and chemicals are locked under the sink and a locked cabinet in the garage and they are all inaccessible to the residents. Each resident bedroom is clean, furnished and have required bedding. The bathrooms are clean, sanitize and in a operable condition. The swimming pool are fenced and locked and inaccessible to residents. The fireplace are covered with screen. The outdoor and passage way are free of obstruction.

4. Staffing: The facility has sufficient number of staffing in the facility. All staff are employed in the facility are over 18 years old. All staff has an updated CPR and First Aid Training. The night supervision staff also have an emergency planned procedure training.

5. Personnel Records/Training: All staff files are maintained in the facility. All the staff employed in the facility are fingerprint cleared and associated with the facility. The administrator is Lorraine Lopez and her administrator certificate will be expired on 11/13/2023 and she has all her required training in file. All staff also have the requried annual Medication Management Training.

6. Resident Records/Incident Reports: All residents files are maintained in the facility and all residents files have the required documents which included admission agreement, functional capacity assessment, physician report with TB Test result, resident appraisal and needs and service plan ..etc.

7. Resident Right-Information: The facility has all the posted near the dining room area which including the personal right of the residents, RCFE complaint poster, non-discrimination notice...etc. The facility also has internet service that provide at lease one internet access device.

8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

9. Food Services: The facility has sufficient food supply including minium 2 days perishable and 7 days non-perishable. The facility kitchen is clean and well kept and in a operable condition. The food are properly stored in the refrigerator to avoid cross contamination.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: VINE RESIDENCE	FACILITY NUMBER: 198603317
	VISIT DATE: 05/23/2023

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
26
27
28
29
30
31
32

10. Incident Medical and Dental: The medication is centrally stored and locked in the hallway cabinet which are inaccessible to residents. LPA inspected all 6 residents medication and they are all seemed updated and accurate.

11.Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) dated on 4/17/2023. The last fire/disaster drill was conducted on 2/10/2023. And also there's at least 2 alternative temporary shelter location

12: Resident with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. Currently there's no resident is receiving oxygen.

LPA did not observe any deficiencies during the annual inspection.

Exit Interview conducted and a copy of the report was emailed to administrator Lorraine Lopez.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3