198603606-2-6-2023-28-AS-VMAO-CNSMPV-20230206084747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603606
Report Date: 02/06/2023
Date Signed: 02/06/2023 08:47:58 AM

Document Has Been Signed on 02/06/2023 08:47 AM - 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:	CLEARWATER AT GLENDORA		FACILITY NUMBER:	198603606
ADMINISTRATOR:	SAMPEDRO, TAMMIE		FACILITY TYPE:	740
ADDRESS:	333 W. DAWSON AVENUE		TELEPHONE:	(626) 885-0140
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	148	CENSUS: 0	DATE:	02/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Tammie Sampedro- Executive Director		TIME COMPLETED:	09:00 AM

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	Please Note: This report supersedes the report dated 1/24/23 to clarify information based on the updated/approved fire clearance for this facility. Licensing Program Analyst (LPA) Valeria Maldonado made an announced visit at the facility for the purpose of conducting the pre-licensing inspection. LPA Maldonado met with Executive Director Tammie Sampedro and explained the purpose for the visit. Tammie Sampedro has a current Administrator Certificate# 6031379740, with expiration date: 06/25/2024. The building is a two-story building that will be licensed to serve 148 residents of ages 60 and over. The fire clearance has been approved for 142 non-ambulatory residents, of which 6 may be bedridden- approved for all first and second floor. Fire clearance is also approved for delayed egress. The facility has a hospice waiver approved for up to 10 residents and an approved dementia care plan. On 1/24/23, an inspection of the physical plant was conducted by LPA Maldonado and Tammie Sampedro, which consisted of the following: the front lobby, the memory care unit, common areas, resident rooms and private bathrooms, public bathrooms, dining rooms, central restaurant style kitchen, offices, housekeeping closets, activity rooms, bar area, beauty salon, theater room, fitness room, massage room, laundry rooms, supply rooms, medication rooms, and outside shaded patio areas with seating. One water fountain was observed in the center of the assisted living side, courtyard; however, it contained no water. The memory care unit is located on the first floor and consists of resident rooms# 123-158, with 8 of the rooms having an approved fire clearance for bedridden residents. A delayed egress door system was observed and the alarm system was tested and operational. The resident rooms# 151 and 152 were observed to have sufficient space to accommodate the resident's furnishings and have all of the required furniture with plenty of personal storage space. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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: CLEARWATER AT GLENDORA	FACILITY NUMBER: 198603606
	VISIT DATE: 02/06/2023

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Resident rooms were also inspected and observed to have a working toilet, wash basin, and shower to accommodate non-ambulatory residents. Each bathroom had the required grab bars and non-skid shower strips. The public restrooms were observed to have working toilets and wash basins. The hand wash stations were fully stocked with sensor liquid soap dispensers and hand dryers- all operational. The assisted living side resident rooms# 114, 115, 258, and 268 were also observed to have sufficient space to accommodate the resident's furnishings and have all of the required furniture with plenty of personal storage space. Resident rooms were also inspected and observed to have a working toilet, wash basin, and shower to accommodate non-ambulatory residents. Each bathroom had the required grab bars and non-skid shower strips. The water temperature in each resident bathroom and public bathroom tested within the required 105*F-120*F temperature, per California Code of Regulations, Title 22. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. The facility has a telephone system is that is a landline and is operational, available for resident use. The facility is also equipped with a call light system that operates from each resident bathroom- they were tested in each inspected room and were operational. Emergency Exit plans are posted and readily available near each elevator door and facility entrances/exits. Several fire extinguishers were located and mounted on the walls throughout the facility and in the kitchen areas- observed to have recent inspections and be fully charged. Dishes, cups and flat ware are stored in the central kitchen and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils are also stored in the central kitchen and are inaccessible to residents in care. The food supply was observed to contain the required 2-day perishables and 7-day non-perishables. Smoke/carbon monoxide detectors were observed in each resident bedroom- tested and operational at the time of the visit. The facility also has an electrical and connected fire system that was tested and operational by Glendora Fire Department on 12/09/22.
All laundry, kitchen, and facility equipment were operating and in good repair. The facility is equipped with central air and heat and each client bedroom is individually climate controlled.
All poisons, toxins, and cleaning supplies are locked in the housekeeping and storage closets and are inaccessible to residents in care. First aid kits were inspected and observed to have the required supplies and first aid manual to meet Title 22 Regulations. All staff and resident files will be kept in the director's office on the first floor.
LPA Maldonado has cleared the physical plant and conducted the Component III Orientation with the applicant. An exit interview was conducted and a copy of this report has been furnished to the applicant. 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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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