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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601953
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:53:25 PM


Document Has Been Signed on 02/13/2024 03:53 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:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR:CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:106CENSUS: 86DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:CECILIA DEGRAFF - EXECUTIVE DIRECTORTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Cecilia “CC” Degraff (Administrator) and Daniel Orozco (Haven Manager) who assisted with the tour, the purpose for today’s visit was explained. The facility is licensed to serve 106 residents (90 non-ambulatory and 16 bedridden) ages 60 and over. The facility has an approved Hospice Waiver on file for twenty (20) residents and are cleared for a delayed egress system.

The Facility is 2 story building located in Sierra Madre, CA. A tour of the facility included: 1st floor (assisted living units with private bath), 42 resident units, large dining room, private dining room, kitchen, bistro, library, cinema, laundry room, multiple staff offices, medication/nurse station, 2 activity rooms, an elevator, public restrooms and 2 courtyards/patios. 2nd floor: (memory care units with private bath – 2 sections “Haven”-late-stage memory care and “Connections”-mild to moderate memory care), 25 units each with private bath; each side of memory care had their own dining area, kitchenette, activity area, living room and patio. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The facility has central air/heating, call buttons in each unit and emergency sprinkler system throughout.



LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, Care of Bedridden Residents Plan and training, and facility maintains the required liability insurance.

(Continued on the 809C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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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Document Has Been Signed on 02/13/2024 03:53 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

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
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed a medication cart a medication cart filled with prescribed medication belonging to various Residents, unlocked and unattended in hallway, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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***Administrator/Director immediately had staff lock cart upon observation, all other medication carts throughout facility (also in hallways) were locked***
Administrator/Director to conduct training and council with all staff that assist with medication, and submit a copy of the training materials and training log with participants to LPA via email by 3/1/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 02/13/2024
NARRATIVE
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Physical Plant & Environment Safety: LPA toured facility, a total of 10 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There are multiple shaded patio/garden areas for residents on each floor.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.
Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 10 staff files with no issues observed. Administrator Cecilia DeGraff certificate expires on 4/27/24.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 10 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.


(Continued on the 809C)
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 02/13/2024
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Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. During tour on the first floor (assisted living) LPA observed a medication cart filled with prescribed medication belonging to various Residents, to be unlocked and unattended in hallway (details will be documented on the 809D), Administrator immediately had staff lock cart upon observation, all other medication carts throughout facility (also in hallways) were locked.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 1/9/24, another was being conducted during todays visit.
Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there deficiencies observed during the visit will be cited on the 809D.

Exit interview held, a copy of the report and appeal rights will be emailed provided to Administrator/Executive Director Cecilia “CC” Degraff.

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena HerreraTELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4