198603585-8-20-2024-28-AS-NGAA-D8BVEJ-20240820162226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603585
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:22:33 PM

Document Has Been Signed on 08/20/2024 04:22 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: 3	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Belen Taico, Assistant Administrator		TIME COMPLETED:	04:25 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Assistant Administrator Belen Taico. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. The facility is located in a residential neighborhood that consists of 4 resident rooms, 2 bathrooms, dining room/ living room, office, laundry room, medication/storage room, outdoor patio area, and detached garage. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A hospice waiver for 4 residents is in place. A fire clearance for (6) non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4 only. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 8/26/2024.

Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility has (3) fully charged fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm in the dining area.

Staffing: A total of 5 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expires 11/14/2025. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HENRIETTA'S HOME	FACILITY NUMBER: 198603585
	VISIT DATE: 08/20/2024

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Resident Records/Incident Reports: A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. Facility does not utilize Medication Administration Records.

RCFE complaint poster and Personal rights were observed posted. However, the RCFE Poster is 8 x 10, instead of 20 x 26 inches. A technical advisory was issued.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. 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. One resident has a modified diet plan.

Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 6/21/2024.

Residents with Special Health Needs: Three (3) residents are receiving hospice services and zero (0) resident receive home health services. All 3 residents have a Dementia diagnosis. Full bed rails for mobility assistance were observed in hospice resident's rooms. No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Assistant Administrator Belen Taico. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/20/2024 04:22 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: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 a total of 3 prescribed ointment creams were observed in an unlocked bathroom drawer, 2 of the creams belonged to 2 former residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/21/2024
	Plan of Correction
1 2 3 4	Submit a written plan by tomorrow and completed staff in-service training on Title 22 87465 by Friday 8/23/2024/

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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 08/20/2024 04:22 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: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 hospice/dementia residents (R1-R3) only have pre-placement and/or resident appraisals completed upon admission, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Administrator shall submit copies of resident (R1-R3's) Appraisal Needs and Services Plans and/or updated care plans.

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: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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