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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604439
Report Date: 06/07/2022
Date Signed: 06/07/2022 06:43:36 PM

Document Has Been Signed on 06/07/2022 06:43 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: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:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stacy Santana Lopez TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with caregiver Carmen Ortiz and explained the reason for the visit. Shortly after, the administrator/licensee Linda Morales and House Manager Stacy Santana Lopez arrived and assisted with the visit. LPA used the infection control tool to evaluate the facility. LPA 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 was approved on 04/18/2021.

The facility is a single story house and located in the residential neighborhood. The facility included living room, dining room, kitchen, 5 bedrooms and 2 bathrooms. All 5 residents bedrooms were toured. Bedroom#1 to #4 has one bed, one drawer, one night stand and required bed linen, furniture and sufficient lighting and closet space. Bedroom#5 has two beds, one drawer, required bed linen and furniture and sufficient lighting and closet space. All two bathrooms were toured and they are clean, sanitary and in a operable condition. They also have required grab bars and non-skid mats. The hot water temperature in two bathrooms were measured between 113.9 and 117.6 degrees F which is within the Title 22 regulation. The refrigerator and kitchen cabinet in the storage room are sufficient for 2 days perishable and 7 days non-perishable food storage. All the appliance in the kitchen are working properly. The common area such as living room and dining room are clean and have the required furniture. The front and back yard are maintained well and the back yard has a shaded are and sitting area. LPA also inspected the carbon monoxide detectors and smoke detectors and they are located in each bedroom and common area and they are working well.

LPA reviewed all 5 resident files to confirm emergency contact is updated. LPA also reviewed 3 staff files to confirm health screenings and fingerprint clearances and they are all fingerprint cleared and updated in the file. LPA reviewed all 5 residents' medications. R1's medication Lacosamide 100mg is not in the facility but listed on the Medication Administrative Record (MARs), R2's medication Alprazolan is in the facility but not on the MARs, R3's medication-Levothyroxine Sodium 75mg is not in the facility but listed on the MARs and R4's medication- Vitamin B-1 is in the facility but was not listed on MARs


SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CON CARINO INC.
FACILITY NUMBER: 197604439
VISIT DATE: 06/07/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility,the facility is disinfected every shift. all bathrooms have sufficient soap, paper towels, and signs, the PPE supplies are sufficient for more than 30 days.

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 Santana Lopez.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/07/2022 06:43 PM - It Cannot Be Edited


Created By: Christine Wong On 06/07/2022 at 10:39 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: 06/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)

87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, LPA observed R1's medication Lacosamide 100mg is not in the facility but listed on the Medication Administrative Record (MARs), R2's medication Melationin 10 mg, Alprazolan, Acetaminophen 500mg, Terazosin HCL 5mg is in the facility but not on the MARs, R3's medication-Levothyroxine Sodium 75mg is not in the facility but listed on the MARs and R4's medication- Vitamin B-1 is in the facility but was not listed on MARs
POC Due Date: 06/08/2022
Plan of Correction
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The administrator will ensure each resident medication, once ordered by resident's primary physican and the medication is given according to the physician's direction. The administrator will retrain the staff for medication training and send the training log to LPA by POC due date and updated all resident's medication/MARs and refill resident medication immediately.
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:Christine Yee
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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