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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603478
Report Date: 07/15/2023
Date Signed: 07/15/2023 04:20:26 PM


Document Has Been Signed on 07/15/2023 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ST. DANIEL'S SENIOR CARE, INC.FACILITY NUMBER:
198603478
ADMINISTRATOR:DANIEL DAVIS JR.FACILITY TYPE:
740
ADDRESS:2403 N. INDIAN HILL BLVDTELEPHONE:
(909) 971-7083
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
07/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff #1TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/15/2023 at 9:25am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for six (6) hospice residents.

LPA OBSERVATIONS: Tour began at 9:55am and was led by S1. The facility is a single-story building located in a residential area with five (5) client bedrooms, one (1) staff bedroom, two (2) bathrooms, kitchen, dining room, living room, TV room, staff office, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed Staff #3(S3) providing meal assistance to Resident #6 (R6) at the dining room table. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 105.9 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area.

Linen Closet: Contained plenty linens, towels, and hygiene products.

SEE 809-C for continuation...

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
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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Document Has Been Signed on 07/15/2023 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. DANIEL'S SENIOR CARE, INC.
FACILITY NUMBER: 198603478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, LPA Ramirez observed section of garage to be sectioned off with wall divider. LPA Ramirez observed the following on other side of divider: Mattress with linen and bed frame, pillows and 1 green plush frog toy, 12 drawer dresser, large flat screen TV sitting on top of dreeser, lamp, plant and decorative accents on a nearby night stand, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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Licensee will contact city to get permit for additional living space in garage or remove make shift staff corridor in garage. Licensee will send proof of permit to allow garage being converted to staff living corridor or picture proof of removed staff bedroom items from garage by 7/29/23.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Staff #1(S1), Staff #2(S2) did not have proof of required 4 hours of postural supports, restricted health conditions, and hospice care, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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Licensee will provide staff with required annual training as specified in HSC 1569.625(b)(2). Licensee will certify via email intent to provide annual training by 7/29/23.
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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 07/15/2023 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. DANIEL'S SENIOR CARE, INC.
FACILITY NUMBER: 198603478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
87411
Personnel Requirements – General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Staff #3(S3) file did not provide proof of health screening, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2023
Plan of Correction
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Licensee will certify via email that all future staff will provide proof of health screening. Licensee will submit S3 health screening by 7/22/23.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 07/15/2023 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ST. DANIEL'S SENIOR CARE, INC.
FACILITY NUMBER: 198603478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1)(2)
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff #3(S3) did not have proof of criminal clearance or criminal record exemption, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/16/2023
Plan of Correction
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Licensee will certify via email that all future staff will have criminal record clearance or criminal record exemption prior to employment or initial presence in the facility. Licensee will remove S3 at this facility until proof of clearance or exemption. Civil Penalty of $100 is being assessed.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2023
LIC809 (FAS) - (06/04)
Page: 5 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. DANIEL'S SENIOR CARE, INC.
FACILITY NUMBER: 198603478
VISIT DATE: 07/15/2023
NARRATIVE
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Resident Rooms 1 - 5: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. Resident rooms appeared to be clean.

Bathrooms: Signs promoting hand washing were observed. Water temperature in resident bathroom#1 was measured at 109.4 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 was observed to be clean and water temperature was measured at 113.2 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms.

Centrally Stored Medications: LPA observed cabinet located in staff office to be locked and inaccessible to residents in care.

Backyard: LPA observed plenty of seating and shade. No large bodies of water were observed. LPA Ramirez observed several discarded wheelchairs and rubbish to be pilled on the side of outdoor pathway leading to the side of the facility.

Emergency Drills: Proof of last documented fire drill was conducted 5/30/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways. LPA Ramirez observed posted Emergency Disaster Plan.

Staff Personnel Files: Staff files are maintained at facility however; staff present at the facility could not gain access and licensee instructed staff to break in file cabinet. Five (5) staff files (S1 – S5) were reviewed. LPA Ramirez reviewed current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file, Criminal record clearance, initial training and annual training. LPA Ramirez could not verify criminal clearance and health screening for S3. LPA Ramirez could verify S1 and S2 completed required annual training of postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696.

Resident Files: Six (6) resident files were reviewed. Admissions agreements and resident personal rights were observed in files.

Liability Insurance & Infection Control Plan: LPA Ramirez reviewed and obtained a copy Infection Control Plan. Licensee provided LPA Ramirez with a copy of liability insurance.

Deficiencies are being cited during visit. Exit interview was conducted S1 and a copy of this report, 809-D, LIC 9102, LIC 421BG and appeals rights were provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2023
LIC809 (FAS) - (06/04)
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