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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603371
Report Date: 10/11/2022
Date Signed: 10/11/2022 01:38:44 PM

Document Has Been Signed on 10/11/2022 01:38 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:CANDLELIGHT HOME GARDENGLENFACILITY NUMBER:
198603371
ADMINISTRATOR:CALINGASAN, GILFACILITY TYPE:
735
ADDRESS:419 SOUTH GARDENGLEN STREETTELEPHONE:
(626) 715-5653
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 3DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Jane CuaTIME COMPLETED:
01:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Jane Cua and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
· LPA and Administrator toured the home and inspected (4) client bedrooms, (2) bathrooms, kitchen, dining room, living room, office room, activity room and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and measured between 114.6F – 115.6F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector in the hallway of the home that was tested and operable. There is a fire extinguisher located in the living room area which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to clients. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to clients. First Aid kit was fully stocked with current manual.
· Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed.
· (3) out of the (3) client medications were reviewed. Medications are centrally stored in a closet located by the dining room. Medications are documented properly and given as prescribed.
· Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there as a deficiency observed during the visit. (Please see 809D for details) Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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 10/11/2022 01:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/11/2022 at 01:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CANDLELIGHT HOME GARDENGLEN
FACILITY NUMBER: 198603371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA and administrator observed expired can goods of pasta sauce as well as buirritos, butter spreads and milk. Also 1 romaine lettuce, 7 tomatoes, 2 plums were not fit for human consumption which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2022
Plan of Correction
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The administrator shall inspect all food storage areas and discard all expired cans. The administrator shall also provide to Licensing a written statement that she inspected the food storage areas, discarded all expired cans/food and will monitor the food supply weekly ensuring there are no expired cans/food. Submit a written plan stating what was done, and proof of staff training by POC due date.

***Administrator discarded all expired and spoiled food during visit***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
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