198603585-8-18-2023-28-AS-NGAA-CUTSMS-20230818140026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:00:33 PM

Document Has Been Signed on 08/18/2023 02:00 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:	(626) 703-4958
CITY:	SAN GABRIEL	STATE: CA	ZIP CODE:	91775
CAPACITY:	6	CENSUS:	DATE:	08/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Reyna Cecilio, Caregiver		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. Caregiver Reyna Cecilio assisted with the visit. Administrator Robin Aquino was explained the purposed of the visit telephonically, but was not able to be present during the visit. There are currently 5 elderly residents 60 years and older and 1 under age 59 residing in the home. Four (4) residents are receiving hospice care, and two (2) residents receive home health care.

The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has and Infection Control Plan.

Operational Requirements:

The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved.
A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room #4 4 only. NOTE: Bedridden resident (R1) is residing in the fire clearance designated bedridden room #4.
Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 8/26/2023.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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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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: 08/18/2023

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Physical Plant/Environment Safety:

The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 1 may be bedridden. It consists of 4 bedrooms; 4 for residents [2 private & 2 shared) and 1 office, 2 bathrooms, living room, dining room, kitchen, outdoor patio area, laundry room, and a 2 car detached garage in the rear of the property presently being used as storage area.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Sharps and toxins were locked.
The facility has two (2) fully charged fire extinguishers, a fire pull alarm, and fire sprinklers.
Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.

Staffing:

A total of 8 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:

Administrator certificates expires 11/14/2023.
Personnel files/training were reviewed. Proof of staff training, health clearance, criminal background clearance and 1st Aid/CPR training were verified. However, staff (S3) began working at the facility on 5/16/2023 and no staff training has been completed/documented on their file. Citation was issued.

Resident Records/Incident Reports:

A total of five (5) resident files were reviewed. Files contained admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
RCFE complaint poster and Personal rights were observed posted in the dining area.

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SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

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: 08/18/2023

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Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.
Indoor and outdoor activities are performed regularly. An activity calendar was posted.
The facility does not have a Resident Council.

Food Service:

Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
Physician orders for modified diets are in place for resident (R1).
Sanitation practices and kitchen cleanliness was observed.

Incident Medical and Dental:

A 30-day supply of centrally stored medications was observed.
Medical and dental transportation is provided by family members.

Disaster Preparedness:

Emergency and Disaster Plan LIC 610E is posted.
The last emergency disaster drill was conducted on June 21, 2023.

Residents with Special Health Needs:

Four (4) residents are enrolled in hospice care and 2 residents receive home health services.
Postural support physician orders are on file. Appraisals were observed in files.
Half and full bed rails for mobility assistance were observed in resident beds. Resident (R1's) bed has full bed rails and is not enrolled in hospice. A citation was issued.
No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.
Exit interview was conducted with caregiver Reyna Cecilio. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/18/2023 02:00 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: HENRIETTA'S HOME	FACILITY NUMBER: 198603585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that resident (R1) is not enrolled in hospice and their bed has full bed rails; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2023
	Plan of Correction
1 2 3 4	Administrator shall remove the full bed rails from R1's bed, and obtain a physician order for half rails. Submit pictures of resident's bed and a copy of the physician orders for half bed rails by tomorrow.

Type A

Section Cited

HSC

1569.72(c)(1)

Residents requiring skilled nursing or intermediate care; bedridden residents Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. (1) The fire safety requirements are met. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that per Physician's Report resident (R1) is bedridden presently located in room #2; which is not designated by the Fire department clearance as a bedridden room. Bedridden room is only room #4; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2023
	Plan of Correction
1 2 3 4	Administrator shall submit a written statement of what was done to correct the POC and if applicable picture proof evidence that resident (R1) was moved to the bedridden room.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 08/18/2023 02:00 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: HENRIETTA'S HOME	FACILITY NUMBER: 198603585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that staff (3) began working at the facility on 5/16/2023 and no staff training has been completed/documented; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Administrator shall submit proof of staff training for staff (S3).

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023

LIC809 (FAS) - (06/04)

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