198603317-5-16-2024-28-AS-CWOG-D5BR4H-20240516124135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603317
Report Date: 05/16/2024
Date Signed: 05/16/2024 12:41:43 PM

Document Has Been Signed on 05/16/2024 12:41 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:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Lorraine Lopez		TIME COMPLETED:	12:50 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 Aura McKenzie. 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. Currently, there are three (3) residents are on hospice. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Facility has an updated infection control plan in place. The facility staff and residents continue to practice the hand washing and disinfecting the facility each shift. The facility has sufficient PPE supplies. All the staff in the facility has the updated Health Screening and TB test result in file. 2. Operational Requirement: The facility has approved for 5 non ambulatory and 1 may be bedridden currently there's only one resident is bed ridden which is within the fire clearance requirement. LPA observed the updated Liability insurance and has the sufficient amount for liability insurance covering injury to residents and guests. The facility has a dementia care plan to accept or retain residents with dementia. 3. Physical plant and Environmental Safety: The facility is a single story house and located around the neighborhood area. The facility include: living room, staff break room with a divider, six residents bedrooms, three residents bathrooms, kitchen, dining area, family room and attached garage. Each resident bedroom has one bed, one chair, one drawer and required furniture and beddings and sufficient lighting and closet space. All three resident's bathrooms are clean, sanitary and in a good working condition. The hot water temperature in all three bathrooms were tested between 114.9 and 120 degrees F. The bathroom has the required non-skid mat and grab bar in the shower. The fireplace in the living room is adequately screened. All the appliances in the kitchen are working properly. The sharp knives and utensils are stored and locked in the kitchen drawer.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: VINE RESIDENCE	FACILITY NUMBER: 198603317
	VISIT DATE: 05/16/2024

NARRATIVE

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All the dish soap are stored and locked under the sink. All cleaning supplies and chemicals are stored and locked in the cabinet located in the garage. All the extra personal hygiene products are stored and locked in the garage cabinet. The facility has a telephone on the premises. The carbon monoxide detector are working well in the facility. The facility has a pool in the backyard and it's locked and gated with a fence. The passageway, walkway and patio are free of obstruction.

4. Staffing: Facility has a sufficient staffing to provide care and supervision to the residents. Each facility staff has an updated First aid and CPR certificate. The NOC shift staff has an updated facility emergency planned procedure training.

5. Personal Records-Training: All staff are over 18 years old, fingerprint cleared and associated with the facility. All staff has the updated training hours. The facility administrator is Loraine Lopez and certificate expire 11/13/2025 and she has the required training hours as a qualified administrator.

6. Resident's Right: The RCFE complaint poster and personal right poster posted on the wall in the living room. The facility has internet service and provide at least one internet access device such as computer or tablet and equipped with video conferencing and residents can have meetings with their family or their physician if needed.

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

8. Food Service: 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. No resident required a modified diet that's prescribed by the doctor. Facility staff will chop the food for resident to prevent choking.

9. Incidental Medical and Dental: The facility will arrange residents' medical and dental appointment if needed. All the resident's medication are centrally stored and locked in the cabinet in the hallway. LPA inspected all six residents medication and they all seemed accurate and updated and they all have 30 days supply of medication.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: VINE RESIDENCE	FACILITY NUMBER: 198603317
	VISIT DATE: 05/16/2024

NARRATIVE

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10. Resident Record-Incident Report: All the resident file in the facility has all the required documents including: face sheet, signed admission agreement, updated medical assessment, functional capability assessment, pre-appraisal and needs and service plan and ambulatory status and medication list in the file.

11. Disaster preparedness: The facility has an updated emergency Disaster plan in place. The facility has at least two appropriate alternative shelter location. The last disaster drill was conducted on 4/17/24. The emergency exit plan and telephone number posted on the wall in the living room.

12. Resident with special health needs: Currently the facility has three residents on hospice and one bedridden and it's within the requirement and fire clearance. All staff does have the required training for the hospice and dementia residents. The hospice residents has the updated information in their hospice record along with the resident's file.

No deficiencies were observed

Exit interview conducted and a copy of the report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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