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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603413
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:20:56 PM


Document Has Been Signed on 03/15/2022 04:20 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:SAGE GLENDALE SENIOR LIVINGFACILITY NUMBER:
198603413
ADMINISTRATOR:BERARD, MARTHAFACILITY TYPE:
740
ADDRESS:525 W ELK AVETELEPHONE:
(626) 253-2929
CITY:GLENDALESTATE: CAZIP CODE:
91204
CAPACITY:113CENSUS: 35DATE:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Administrator Elizabeth WhittingtonTIME COMPLETED:
04:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Ana Manukyan, Front desk and Administrator Elizabeth Whittington, LPA explained the purpose of the visit. Administrator certificate expires 09/28/2022 Last fire drill was on 02/272022

Structure:
The facility is a 5 story building with underground parking. 1st floor contain common areas. 2nd floor is for Memory Care. 3rd to 5th floor is for Assisted Living. The passageways and walkways are free of hazard and free from obstruction.
The following were observed/inspected:

· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between measured between 74 – 113.7 degrees F which is not within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does has one designated isolation room. Facility Assistant Administrator will put them up in hotel
· Six client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Not all client rooms were not equipped with alcohol-based hand sanitizer, but readily available to all residents.
· Four (4) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (please see 809D)

· Exit interview was conducted with Administrator Elizabeth Whittington. A copy of the report was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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 03/15/2022 04:20 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: SAGE GLENDALE SENIOR LIVING
FACILITY NUMBER: 198603413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the water in the 1st floor resrtrooms sinks measured 74 degrees F. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
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Administrator will hire plummer to adjust water temperture in the first floor restroom facets and send photo as proof of crrection by POC 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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