198603752-9-10-2024-28-AS-DKOI-D8YRA6-20240910125036

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603752
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:51:35 PM

Document Has Been Signed on 09/10/2024 12:51 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	INSPIRED ELDERLY CARE LIVING II		FACILITY NUMBER:	198603752
ADMINISTRATOR:	GALLEGOS, LAURIE		FACILITY TYPE:	740
ADDRESS:	627 N. JANSEN AVE		TELEPHONE:	(909) 240-1321
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	6	CENSUS: 0	DATE:	09/10/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Laurie Gallegos, Licensee/Administrator		TIME COMPLETED:	01:00 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) Daniel Konishi made an announced visit and met with Licensee/Administrator, Laurie Gallegos conduct a announced Pre-Licensing evaluation. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. Approved for six (6) ambulatory, of which five (5) may be non-ambulatory residents. Bedrooms#2 and 4 are approved for two (2) non-ambulatory. Bedroom #3 is approved for one (1) non-ambulatory and Bedroom #1 is approved for one (1) ambulatory hospice waiver granted for six (6) residents. Structure: Facility is a single-story home located in a residential area consisting of four (4) bedrooms, one (1) bathroom, kitchen, dining room, living room, family room, garage, and a backyard with seating and shade. Front entry and all exits have a wheelchair ramp. Operational Requirements: The facility did not have proof of liability insurance during today's visit and that they were instructed to obtain the liability insurance prior to accepting the first resident and will submit proof of that insurance to the department once it is obtained. Bedroom Clients: Bedrooms are equipped with a bed, night stand, chair, lamp, dresser, trash bins, and overhead lighting. Bathrooms: One (1) full bath equipped with working toilet, wash basins, bathtub/shower and One (1) full bath equipped with working toilet, wash basins, walk in shower. 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 linen closets. Emergency Phone Numbers, Exit Plan: Emergency numbers and Exit plans are posted and readily available for review. Three (3) fully charged fire extinguishers was observed. 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. Emergency water supply was observed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INSPIRED ELDERLY CARE LIVING II	FACILITY NUMBER: 198603752
	VISIT DATE: 09/10/2024

NARRATIVE

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Carbon Monoxide/Smoke Detectors: Where observed and tested. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in good condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was within normal limits 105 degrees Fahrenheit and not more than 120 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, 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. Resident & Staff Files: Designated area for files will be in locked closet. Pools/Jacuzzi/Body of Water: No bodies of water were observed. Fire Clearance: Fire clearance was approved on 07/05/2024 for six (6) ambulatory, of which five (5) may be non-ambulatory residents. Bedrooms#2 and 4 are approved for two (2) non-ambulatory.Bedroom #3 is approved for one (1) non-ambulatory and Bedroom #1 is approved for one (1) ambulatory hospice waiver granted for six (6) residents. Component III: Component III was reviewed during inspection.

Pre-Licensing is complete, and this facility has no deficiencies. Exit interview was conducted with the Licensee/Administrator, Laurie Gallegos and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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