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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 01/06/2024
Date Signed: 01/06/2024 01:05:46 PM


Document Has Been Signed on 01/06/2024 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:HASTINGS RANCH HOMEFACILITY NUMBER:
198603391
ADMINISTRATOR:ESTANISLAO, RALPHFACILITY TYPE:
740
ADDRESS:1230 HASTINGS RANCH RDTELEPHONE:
(626) 351-1150
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 5DATE:
01/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:William Carreon - CaregiverTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met William Carreon with and explained the reason for the visit.

The facility is licensed to serve 5 non-ambulatory and 1 bedridden residents over the age of 60, with an approved hospice waiver for 6. The facility has 5 bedrooms, 3 bathrooms, a living room, a dining room, an activity room, a kitchen and an attached garage. The outdoor facility has a front yard, and back patio.

LPA toured the facility with William Carreon and observed the following:
Facility is in good repair inside and outside. Common areas: Living room, dining room, and TV area are clean with furniture in good repair. Fireplace is cover. Each resident rooms (5) have sufficient lighting, the required furniture and bedding supplies. Room # 2's bed was observed with full bed rails, resident is in hospice and has a request on file. Room #3's bed was observed with half bed rails, Resident #3(R3) does not have a physician's order on file. Administrator has document the request submitted to the physician. Bathrooms were observed (3) each is in working condition, showers have grab bars and skid mats. Water temperature was tested between 107.2-110.1 degrees F., which is within the required 105-120 degrees F. Kitchen was observed clean. Sharps were observed locked in a drawer. Medication cabinet was observed locked. Food supplies were observed sufficient for at least (7) days of non-perishables and (2) days of perishables and emergency food supplies are stored. Cleaning supplies were observed locked in the garage. Garage is used as storage. Backyard, passageways, and front yard are free of debris and have shaded seating area.

LPA reviewed files and medication for 5 residents. Resident #1(R1) last physician's report is dated 3/3/21 and Resident #4(R4)'s last physician's report is dated 8/24/22 both residents have a dementia diagnosed, and Resident #2(R2)'s admission agreement is missing signatures. LPA reviewed 4 staff files.

(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
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 4


Document Has Been Signed on 01/06/2024 01:05 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in R3 does not have a written physician's request for half bed rails on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Administrator will follow up and obtained the physician's request for half bed rails for R3 and will submit a copy to the department by POC due date 1/15/24.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R1 last physician's report is dated 3/3/21 andR4's last physician's report is dated 8/24/22which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/15/2024
Plan of Correction
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Administrator will obtain a current physician's report for R1 and R4 and will submit a copy to the department by POC due date 1/15/24.
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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391
VISIT DATE: 01/06/2024
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LPA reviewed infection control plan and disaster plan. Last fire drill was conducted on 12/1/23. Administrator's certificate was reviewed for Ralph Estanislao #6053102740 exp 3/17/25.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4