198603662-5-25-2023-28-AS-ALOZ-CS6TY3-20230525150805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603662
Report Date: 05/25/2023
Date Signed: 05/25/2023 03:10:26 PM

Document Has Been Signed on 05/25/2023 03:10 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:	GLENDORA CARE HOMES		FACILITY NUMBER:	198603662
ADMINISTRATOR:	SANTOS, LUIS GABRIEL		FACILITY TYPE:	740
ADDRESS:	339 W. CITRUS EDGE STREET		TELEPHONE:	(909) 592-6497
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY:	6	CENSUS: 0	DATE:	05/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Santos, Luis Gabriel, Administrator, Apolonio Licensee and Rowena Santos		TIME COMPLETED:	03:17 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) Alberto Lopez conducted an announced visit to the facility for the purpose of a pre-licensing inspection. Upon arrival, LPA met with Apolonio (Licensee), Rowena (House Manager) and Luis Gabriel Santos (Administrator) who assisted with the inspection. An application was submitted on 12/27/22, for Initial License for Adult Resident Facility for Elderly to serve age range 60 and older The facility is a one-story building which consist of the following: 5 client bedrooms, of which one is shared and one bathroom, one staff bathroom, dining room, living room, attached garage and kitchen. Washer and dryer are in the garage area. LPAs utilized the Compliance and Regulatory Enforcement (CARE) Tools which contain the following domains: Physical Plant & Environment Safety, Operational Requirements, Staffing, Personnel Records/Training, Residents records/Incident Report, Resident rights information, Food Services, Residents with special health needs, Planned activities, incidental medical and dental, and Disaster Preparedness. During today's inspection, LPAs observed the client bedrooms are spacious and easily accommodates the client's furnishings. Bedrooms have one bed, chair, one night stand, one lamp. One shared room has 2 two chairs, two night stands, two beds and linens in addition to overhead lighting. The bathrooms have a working toilet, wash basin, bathtub but missing toilet grab bar. Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in storage closet. Emergency Phone Numbers, Exit Plan & Menu are posted & readily available for review. Two fire Extinguisher mounted to the walls throughout the entire facility. Telephone system is a land line located in the kitchen. Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Continue to LIC809C.....

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLENDORA CARE HOMES	FACILITY NUMBER: 198603662
	VISIT DATE: 05/25/2023

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Food supply adequately stored in kitchen freezer and food storage room. Smoke Detectors and Carbon monoxide detector are operational. Stove burners, oven, washer, and dryer are working. Toxins are locked and stored in the separate storage compartment. Hot water temperature was tested throughout the facility and measured 126.9 to 134.4 degrees F which is not within Title 22 guidelines. A first aid kit has been inspected and consist of the following: thermometer, tweezers, scissors, antiseptic, bandages and gauze, which are stored in the medication cabinet for staff use but inaccessible to clients. There are no Pool/Jacuzzi & Pets on the premises. Fire Clearance was approved on 04/13/2023.

Component III: Was presented to Apolonio (Licensee), Rowena (House Manager) and Luis Gabriel Santos (Administrator)

During the pre-licensing inspection certain items were observed which do not comply with applicable laws and regulations; the following items must be corrected, and proof of correction shall be submitted to the CCLD office to the attention of LPA Lopez by 06/01/23. 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. Two perimeter doors on the two sides of home need to be repair or replaced to allow residents, staff and visitors to exit.
2. Licensee will obtain Ombudsman poster and post it in facility
3. Proof or required liability insurance
4. Solid wastes containers shall have tight-fitting covers on the containers
5. Storage and preservation of medications, including the storage of medications that require refrigeration.
6. Water temperature will be adjusted to between 105 – 120 degrees F. and proof sent to LPA.

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 Centralized 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. A follow up inspection may be conducted to inspect the necessary corrections.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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