198603410-5-5-2023-28-AS-ALOZ-CRJUMY-20230505154306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:43:17 PM

Document Has Been Signed on 05/05/2023 03:43 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:	LA CASITA RESIDENTIAL CARE INC.		FACILITY NUMBER:	198603410
ADMINISTRATOR:	SANTAMARIA, HUMBERTO		FACILITY TYPE:	740
ADDRESS:	700 N. GRAND AVE.		TELEPHONE:	(626) 387-9987
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91741
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Humbeto SantaMaria, Licensee		TIME COMPLETED:	03:59 PM

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Licensing Program Analyst (LPA) Alberto Lopez conducted an annual required visit. LPA met with Licensee Humberto Santamaria and explained the reason for the visit. Home has a fire clearance from the local Fire Department for a capacity of 6 non-ambulatory and hospice waiver for 6

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection control plan at facility.
Physical Plant & Environment Safety: . There are 6 client bedrooms, 1 shared rooms 2 bathrooms, 2 with showers, living room, activity room, dining room, kitchen, laundry room, attached garage used as storage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway and was tested. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in measured 115.8- 118.0 degrees F which is within the required range of 105-120 degrees F.
Operational Requirements The licensee provides care and supervision as required.
Staffing: There appears to be sufficient staffing at the facility. The administrator’s certificate expires 12/21/2025 Staff employed are all over the age of 18.
Planned Activities: Facility staff encourage residents to participate in activities.

Continued on 809C

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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: LA CASITA RESIDENTIAL CARE INC.	FACILITY NUMBER: 198603410
	VISIT DATE: 05/05/2023

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Resident Rights/Information: Resident rights are posted at facility and staff are familiar with resident rights.
Personnel Records-Training: Staff files are maintained at the facility. All staff have current CPR first aid training. Facility has documentation on file that verify CPR for all staff.
Client’s Records-Information: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, pre-admission assessment and other required documentation. Some files were missing complete information on physician’s report.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Health Related Services: Clients are assisted with medication administration and dental and medical appointments including arranging transportation.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 5 client’s medication and medication is administered following physician’s orders. PRN letters were missing details and doctor signature, corrected during visit.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drill 4/27/2023

During the visit today, LPA did not observed deficiencies at time of visit. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Licensee Humberto Santamaria

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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