198603585-7-26-2022-28-AS-NGAA-CGPVAG-20220726161555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:16:00 PM

Document Has Been Signed on 07/26/2022 04:16 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:	HENRIETTA'S HOME		FACILITY NUMBER:	198603585
ADMINISTRATOR:	AQUINO, ROBIN		FACILITY TYPE:	740
ADDRESS:	131 SEGOVIA AVENUE		TELEPHONE:	(213) 478-0460
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Stephany Perez, Director of Assisted Living Operations		TIME COMPLETED:	04:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Galarza made an announced visit and met with Director of Assisted Living Operations Stephany Perez to conduct a pre-Licensing evaluation. Licensee Mona Alcaraz was not present, and Administrator is on leave. The facility has a Dementia plan and hospice waiver for four (4) residents. An application was submitted to Community Care Licensing Department (CCLD) on 5/11/2022 for a change of ownership of an RCFE (Residential Care For the Elderly) facility. The requested capacity is for six (6) non-ambulatory residents; of which one (1) may be bedridden. Structure: Facility is a single-story home consisting of four (4) bedrooms [room #4 is bedridden], two (2) full bathrooms, kitchen, dining room, living room, laundry room, medication room/storage, office, and a 2-car detached garage.The front and backyard have grassy areas. The backyard has shaded patio furniture. Bedroom Clients: Bedroom #1 & #4 are shared, and rooms #2 & #3 are private. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning. Bathrooms: Have a working toilet, wash basin, and bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Three (3) fully charged fire extinguishers are in place. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in new condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. See LIC 809C for continuation of report.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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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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: HENRIETTA'S HOME	FACILITY NUMBER: 198603585
	VISIT DATE: 07/26/2022

NARRATIVE

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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications are stored in the medication room/storage room, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the dining room. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance is approved on 6/1/2022 for six (6) non-ambulatory residents. The facility has no delayed egress. The facility has a sprinkler system. Component III: Component III PowerPoint presentation was conducted.

The following item must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by Friday August 5, 2022. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. The wall in the dining room was moved to make larger the office room/area. Upper wall area is unfinished.
Plaster was observed. The wall needs to be finished and painted.

2. Bedroom #4 has a wall section that needs to be cleaned and/or painted.

An exit interview was conducted, and a copy of this report has been furnished to Director of Assisted Living Operations. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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