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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603680
Report Date: 02/17/2022
Date Signed: 02/17/2022 01:00:14 PM

Document Has Been Signed on 02/17/2022 01:00 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAMPTON GUEST HOME, INC.FACILITY NUMBER:
197603680
ADMINISTRATOR:YANG, ERLINDAFACILITY TYPE:
740
ADDRESS:3790 HAMPTON RD.TELEPHONE:
(626) 351-1215
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Remedios Villanueva - Caregiver
Jeff Yang - Administrator 		TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Flores conducted a case management visit -health check during a complaint investigation visit on 2/17/22 due to deficiencies observed. LPA Flores met with Remedios Villanueva caregiver and explain the reason for the visit. Administrator Jeff Yang arrived 45 minutes later.

LPA Flores conducted a Health and Safety Check tour with Remedios Villanueva caregiver around 9:50am and observed the following: Kitchen has sufficient food for at least 2 days of perishables and 7 days of non perishables supplies. Medication prepared for the day in label ziplock bags and large scissors were observed in a kitchen drawer to the right of the stove with no lock. Ajax and bleach solution was observed under the sink without lock, lysol spray and cleaning solutions in hallway closet without lock. All bedrooms have sufficient lighting, furniture and bedding required. Each resident's bedroom was observed to have a video/camera monitor. Cameras were observed throughout the facility. Room #3 is currently under renovation. LPA observed PRN medication in bedroom #4 in resident's night stand. Water temperature was tested at 123.1 degrees F. in bathroom #1, tested at 119.8 degrees F. in bathroom #2, and tested at 120.6 degrees F. in bathroom #3 which is not within the required temperature. Smoke/carbon monoxide detectors were tested and in working condition. Fire extinguisher was observed on hallway wall by kitchen and bathroom #1 last checked on October 2021. Facility is following COVID recommendations. Pool was observed to have a 5ft fence.

Deficiencies were noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8.

Exit interview was conducted with Jeff Yang and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 3
Document Has Been Signed on 02/17/2022 01:00 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/17/2022 at 11:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
87705(f)(2)

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87705 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,... cleaning supplies and disinfectants.
This requirement is not met as evidence by:
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Administrator will ensure that all cleaning, disinfecting supplies, and PRN medication are stored inaccessible at all times, will provided in-service training to staff, and submit a copy of sign-in sheet, agenda to the department by 2/18/22
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Based on observation licensee did not ensure that PRN medications for Resident #2 in bedroom #4 were not in nightstand, bleach solution and ajax were not kept under kitchen sink, and lysol, cleaning solutions in hallyway withou lock which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/18/2022
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained...: (2) Faucets used by residents for personal care... Hot water temperature ... of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidence by:
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Administrator will ensure that water temperature is withing the required 105 - 120 degrees F at all times by certifying in LIC 9098 will submit form to the department by 2/18/22.
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Based on observation licensee did not ensure water temperature was within the required temperature in bathroom #1 which tested at 123.1 degrees which poses an immediate health, safety, or personal rights risk to 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/17/2022 01:00 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/17/2022 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAMPTON GUEST HOME, INC.
FACILITY NUMBER: 197603680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidence by:
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Administrator removed all camera monitors from each room during the visit. Deficiency cleared 2/17/22.
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Based on observation administrator did not ensure residents were treated with dignity and the residents rights to privacy by keeping a video survellaince monitor in each resident's rooms and monitor through an app in administrator's cellphone which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/18/2022
Section Cited
CCR87705(f)(1)

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Care of 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 requirements is not met as evidence by:
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Administrator will ensure that all sharps, tools, are kept locked at all times and will provide in-service training to staff, will submit copy of sign-in sheet, and agenda by 2/18/22.
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Based on observation licenseee did not ensure large scissors were not kept in drawer by stove which poses an immediate health, safety, or personal rights risk to 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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