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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603532
Report Date: 02/10/2024
Date Signed: 02/10/2024 05:38:52 PM


Document Has Been Signed on 02/10/2024 05:38 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:CHALET TERRACE SENIOR LIVINGFACILITY NUMBER:
198603532
ADMINISTRATOR:PALOMINO, AMANDAFACILITY TYPE:
740
ADDRESS:1064 CHALET TERRACETELEPHONE:
(323) 353-1167
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY:6CENSUS: 6DATE:
02/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Caregiver Liseth RamosTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 02/10/2024. LPA was met by Caregiver Liseth Ramos and explained the purpose of the visit. Administrator Amanda Palomino arrived 1 /12 later to assist with tour. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory and has a hospice waiver approved for four (4). Two (2) out of the six (6) residents in care are currently on hospice care.

LPA OBSERVATIONS: The facility is a single-story dwelling located on in a residential neighborhood and consists of three (3) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, detached garage, front yard, and backyard. LPA Ramirez observed auditory device on entry of door to be operational, sliding door and exits.

Front Yard: Is well maintained and no hazards were observed during visit.

Kitchen: 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 appliances were observed to be clean and in working order. LPA Ramirez observed staff preparing lunch for residents during visit. LPA Ramirez observed a 22 – 32 inch monitor that was displaying live video feed of common areas and shared resident rooms. Monitor was observed to be mounted near sink area and accessible to residents, staff, and visitors. LPA Ramirez will issue Technical Violation.

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 near by thermostat to read 72 degree F. LPA Ramirez observed five (5) out of the six (6) residents seated in this area during the visit.

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: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2024
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: CHALET TERRACE SENIOR LIVING
FACILITY NUMBER: 198603532
VISIT DATE: 02/10/2024
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Laundry room: LPA Ramirez observed detergents and disinfectants to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed two (2) emergency food bucket in laundry cabinet.

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



Resident Rooms 1-3: All resident rooms are shared and LPA Ramirez observed a camera mounted in the corner of resident room. LPA Ramirez observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens.

Bathrooms 1-2: Water temperature in two (2) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked. LPA Ramirez observed signage promoting proper handwashing etiquette.

Backyard: Well maintained and no hazards were observed. Plenty of shade and seating was observed.

Garage: LPA Ramirez observed extra PPE supply in this area and emergency water supply.

Emergency Drills/Emergency Disaster Plan: Last documented drills were conducted on 12/01/23 and 09/01/23. Emergency disaster plan was observed and reviewed.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. LPA Ramirez observed fire extinguisher near kitchen to be fully charged.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for four (3) staff. LPA Ramirez observed Administrator’s certificate for Amanda Palomino with an expiration date of 06/15/2024.

Resident Records: Six (6) resident records were reviewed.

Liability Insurance & Infection Control Plan: LPA Ramirez requested and obtained a copy of liability insurance and infection control plan.



Exit interview was conducted. No deficiencies were observed. A copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC809 (FAS) - (06/04)
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