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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 04/02/2024
Date Signed: 04/02/2024 03:15:33 PM


Document Has Been Signed on 04/02/2024 03:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:LA CASITA RESIDENTIAL CARE INC.FACILITY NUMBER:
198603410
ADMINISTRATOR:SANTAMARIA, HUMBERTOFACILITY TYPE:
740
ADDRESS:700 N. GRAND AVE.TELEPHONE:
(626) 387-9987
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Humberto Santamaria- Licensee/AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Licensee/Administrator, Humberto Santamaria, and explained the purpose for the visit.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Licensee, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (6) staff files, and conducted interviews with (2) staff, and attempted interviews with (6) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. The fire clearance is approved for (6) non-ambulatory residents and has an approved Dementia Care Plan. Facility has an approved Hospice Waiver for (6) residents. There are currently (4) residents receiving hospice care. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file, as required.

LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are (2) full bathrooms in the home- both equipped with required grab bars and non-skid mats. The hot water was tested and measured at 114*F, which is in compliance. Food supplies was observed and was sufficient as required. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. Fire extinguishers were observed throughout, with current inspections and were fully charged. Smoke/Carbon Monoxide detectors were tested and observed operational, during the visit. The last fire drill was conducted on 01/14/2024. An auditory devices is installed and interconnected at the home. It was observed to operate for all entrances/exits of the home, as required. LPA observed several surveillance cameras in the front yard, back yard, and common areas inside the home. Per Licensee, the surveillance cameras have been installed and operational since they were first established in 2013, prior to the change in ownership and remained operation through the change in ownership.
(Report Continued on LIC809-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410
VISIT DATE: 04/02/2024
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LPA reviewed the Plan of Operation provided by Licensee for this facility and was unable to confirm the approval of use of surveillance cameras. Resident files were reviewed and observed to be complete with all the required documentation. Staff files were reviewed. (2) of (6) staff files were missing the required Health Screening. Resident medications were reviewed. Resident#5 (R5) had several stored medications that are being administered without written prescriptions on file, and one of the medication bottles was empty, requiring a refill. Per Licensee, R5's family is responsible for refilling and providing the documents to Licensee. However, after many attempts of speaking with the family to resolve the matter, Licensee has been unsuccessful with the medication requirements/needs from R5's family.

Per California Code of Regulations, Title 22, Deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/02/2024 03:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 (2) of (6) staff missing health screening on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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(2) Staff in question will obtain a Health Screening and a copyof the completed report will be provided to LPA, via email, by POC due date.
Deficiency Dismissed
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) …Residents shall have…the following personal rights: (1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in surveillance cameras in use, without proper waiver/approval from the department, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee has turned off the surveillance cameras and will submit a written request for a waiver to the department by POC dute. LPA has provided the Licensee with guidance on the waiver request.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/02/2024 03:15 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care

(h)The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…

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 several of R5's medications without record of centrally stored medications, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Licensee will obtain record of R5's centrally stored prescribed medications and submit to LPA, via email by POC due date.
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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4