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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604439
Report Date: 06/23/2021
Date Signed: 06/24/2021 10:22:09 AM

Document Has Been Signed on 06/24/2021 10:22 AM - 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:CON CARINO INC.FACILITY NUMBER:
197604439
ADMINISTRATOR:GUTIERREZ, CHRISFACILITY TYPE:
740
ADDRESS:1260 N. SIERRA BONITA AVETELEPHONE:
(626) 794-2105
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 5DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:House Manager- Stacy Lopez TIME COMPLETED:
11:15 AM
NARRATIVE
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On the above date, Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with staff Yanette Abzun and explained the reason for the visit and assisted with the tour of the facility. Shortly after, the house manager Stacy Lopez arrived. LPA used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and approved on 04/18/21.

The facility is a single story house and located in the residential neighborhood. The house consists of 5 bedrooms, 2 bathrooms, kitchen, dining area and living room. Each bedroom has a smoke detector, bed, required linen, dresser, chair, sufficient light and closet space .All 2 bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water in the bathrooms and kitchen was measured between 117.9 to 119.3 degrees F. The food in the kitchen and storage room has sufficient supply of 2 days perishable and 7 days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area.

LPA's reviewed 5 resident files to confirm emergency contact is updated. LPA's also reviewed 4 staff files to confirm health screenings and fingerprint clearances. Staff#1 did not have a health screening on file and Staff#2 did not have TB test result on file. LPA's reviewed 5 residents' medications. Resident #4 (R4's) Lexapro 10 mg were not present at the facility. Staff indicated the medications had run out and will deliver today.

The deficiencies cited are documented on the attached 809D. Exit interview conducted. A copy of the report and appeal rights will be provided to house manager Stacy Lopez.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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 2
Document Has Been Signed on 06/24/2021 10:22 AM - It Cannot Be Edited


Created By: Christine Wong On 06/23/2021 at 10:25 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: CON CARINO INC.
FACILITY NUMBER: 197604439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
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While LPA reviewed Staff record and observed Staff#1 does not have health screening in file and S2 does not have any chest x ray result in file which result in the potential risk to health and safey risk to residents
POC Due Date: 07/07/2021
Plan of Correction
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The facility administrator will ensure all employee should have health screening in file and a chest x ray result in file. Administrator will send the copy of the health screening for S1 and S2 to LPA by POC due date
Type B
Section Cited
CCR
87465(c)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident#4's medication for Lexapro 10mg and medication was out and no medication was in the faciltiy during the inspection which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2021
Plan of Correction
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The facility administrator will ensure all residents , Once ordered by the physician the medication is given according to the physician's directions and ensure there will be 30 days medication refilled in the facility and will send the copy of the picture of the medication to LPA by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


LIC809 (FAS) - (06/04)
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