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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607558
Report Date: 11/02/2021
Date Signed: 11/10/2021 10:27:13 AM

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:CARTER PLACE, THEFACILITY NUMBER:
197607558
ADMINISTRATOR:ARGIRI BRATAKOSFACILITY TYPE:
740
ADDRESS:400 W. CARTER AVE.TELEPHONE:
(626) 374-4920
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:6CENSUS: 6DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Crystal GalvanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/2/2021 Licensing Program Analysts (LPAs) Nina Galarza and Joe Katrdzhyan conducted an unannounced annual inspection. LPAs met with Crystal Galvan and stated the purpose of the visit.

LPAs conducted a tour of the inside and outside of the one story house that is located in a residential neighborhood. The home consists of (5) resident bedrooms (4 private and 1 shared), (4) resident bathrooms, (1) staff bathroom, living room, dining room, kitchen, laundry room, deck with patio cover and (1) rectangular table with 6 chairs. The front yard is well landscaped with a ramp that leads to the entrance. The backyard is completely fenced with self-latching mechanism gate. A shaded area with chairs is provided in the back yard. The outdoor activity area is free of visible hazards and debris and the trash cans have covered lids. The fireplace is secured with a covered screen. There is a functioning telephone on the premises, and there are emergency lighting, such as flashlights and night lights. The facility has central air and heating. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2- day supply perishable and 7-day supply of non-perishable foods are present in the facility. There is a storage in the back yard with additional storage of food supply. Emergency Water and food located outside backyard shed. Staff are following modified diets as prescribed by doctors orders. A comfortable temperature was observed.

LPA observed the following during inspection of residents rooms: mattresses are in good condition,adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA observed each resident has extra bed linen and towels in their room. Extra toiletries supplies are present. Bathroom fixtures are clean and working properly and contain the required nonskid mats and grab bars. Water temperature was tested in all bathrooms and were found to be 105-120 degrees Fahrenheit.
CONTINUED 809-C
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 6
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: CARTER PLACE, THE
FACILITY NUMBER: 197607558
VISIT DATE: 11/02/2021
NARRATIVE
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The facility has (1) Carbon Monoxide and (10) Smoke Detectors, hard wired and connected, were tested and working properly. The facility (1) Fire Extinguisher was checked and found to be fully charged and accessible. Medications are centrally stored and in a locked storage cabinet. Outside grounds were toured and no bodies of water were observed. Outside patio accessible to residents.

The following deficiencies were observed during the visit:
· At 12 p.m. no COVID informational signs in front door area and shared bathroom
· At 12:05 LPAs were not screened for COVID upon entry
· At 12:28 p.m. an ax and shovel observed by side yard kept unlocked and accessible to residents
· At 12:28 p.m. debris including but not limited to: a discarded mattress, discarded bed frame, propane tank, wheel barrel by side yard
· At 12:39 p.m a roach on bathroom windowsill near tooth brush in room 2
· At 12:41 p.m. door handle in disrepair on shared bathroom door between rooms 3 and 4
· At 12:43 p.m. Resolve- chemical accessible to residents in room 2
· At 12:43 p.m. medications accessible to residents in room 2
· At 1:15 p.m. all 3 exit doors did not have operable auditory chimes

Due to time constraints LPAs had to terminate visit and will return on a later date to conclude the Required - 1 Year Inspection by focusing on the infection control domain and reviewing client medications.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)

An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: CARTER PLACE, THE
FACILITY NUMBER: 197607558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
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LPAs observed all 3 exit doors did not have operable auditory chimes, which poses an immediate health and safety concern for persons in care.
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Type A
11/03/2021
Section Cited

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87705 Care for Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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 LPAs observed 2 pairs of scissors in room 2, which poses an immediate health and safety concern for persons in care.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: CARTER PLACE, THE
FACILITY NUMBER: 197607558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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LPAs observed a shovel and ax by side yard of house. LPAs observed Resolve chemical accessible to residents in room 2. LPAs observed over the counter medication, COLD RELIEF, Mucus Relief 400 mg, Diclofenac Sodium 1% accessible to residents in room 2,At 12:43 p.m. LPAs observed Resolve- chemical accessible to residents in room 2 which poses an immediate health and safety risk to persons in care.
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Type B
11/12/2021
Section Cited

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Personal Accomodations and Services (d)The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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At 12:28 p.m. LPAs observed debris including but not limited to: a discarded mattress, discarded bed frame, propane tank, wheel barrel and by side yard.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: CARTER PLACE, THE
FACILITY NUMBER: 197607558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited

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Maintenence and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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At 12:41 p.m. LPAS observed door handle in disrepair on shared bathroom door between rooms 3 and 4.
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: CARTER PLACE, THE
FACILITY NUMBER: 197607558
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
This requirement is not met as evidenced by:
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LPAs were not screened for COVID symptoms upon entry. 12 p.m.n LPAs observed no COVID informational signs in front door area and shared bathroom
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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Nina GalarzaTELEPHONE: 323-981-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6