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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603473
Report Date: 08/25/2023
Date Signed: 08/25/2023 11:21:26 AM


Document Has Been Signed on 08/25/2023 11:21 AM - 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:ST. CECILIA'S SENIOR HOME IIIFACILITY NUMBER:
198603473
ADMINISTRATOR:POORTEN, JOSIAH VANDERFACILITY TYPE:
740
ADDRESS:260 N. LONE HILLTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
08/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Tiffany Van PootenTIME COMPLETED:
11:37 AM
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Licensing Program Analysts (LPAs) Alberto Lopez and SanJay Vaid conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Staff Orlando Dipon and explained the purpose of the visit. Licensee Tiffany Vander Poorten arrived a few minutes later.

LPA 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 after changing a resident. Staff are still cleaning and disinfecting throughout the day. Sufficient PPE supplies and has an Infection Control Plan at facility.
Physical Plant & Environment Safety: The 1-story facility is good repair. Fire and carbon monoxide detectors are in every room and were operation. Fire extinguisher are located at facility and serviced. The 1-story facility consist of the following: Four Bedrooms, 2 shared resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, office, and patio/deck area and attached garage.
Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof of enough liability insurance covering injury to residents and guest. Water temperature measured 105.0 – 105.3 which is within required range.
Staffing: There appears to be sufficient staffing at the facility. The administrator’s Josiah Vander Poorten certificate expired 11/11/2023. Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Pre-Admission Agreements, Physicians report, personal rights, and other required documentation. One resident file was updated during visit.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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 6


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: ST. CECILIA'S SENIOR HOME III
FACILITY NUMBER: 198603473
VISIT DATE: 08/25/2023
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Residents Rights-Information: The Complaint poster and personal rights are posted by the main entry.
Food Service: Facility has 2 days perishable food and 7 days nonperishable food at time of visit.
Incidental and medical services: Medication files were reviewed for all 6 residents and all medication is administered properly as doctor ordered.
Planned Activities: Facility has planned activities and supplies and space for activities.
Disaster Preparedness: The facility has an Emergency Disaster Plan at facility with emergency contact numbers and at least 2 relocation sites.
Residents with Special health needs: Facility does not have any residents with special health needs at the time of visit.

During today’s visit, no deficiencies were observed technical advisories were provided, exit interview conducted and report provided to Licensee Tiffany Van Poorten

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6