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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604439
Report Date: 06/13/2023
Date Signed: 06/14/2023 12:05:27 PM

Document Has Been Signed on 06/14/2023 12:05 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: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: 6DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Linda MoralesTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/13/2023 at 9:00 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Linda Morales arrived later to the facility. The facility is licensed to serve residents over the age of 60 years old. The facility has a fire clearance approved for six (6) non-ambulatory and approved for one (1) hospice waiver. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

LPA OBSERVATIONS: Tour began at 9:51 am and was led by S1. The facility is a single-story building located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, front yard, backyard, shed and detached garage.

· Front Yard: Was clean and well maintained. No hazards were observed.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA observed knives and sharps located in nearby cabinet to be inaccessible to 6 out of 6 clients in care. LPA observed several bottles of cleaning solutions and disinfectants under kitchen sink cabinet to be inaccessible to 6 out of 6 clients in care.

· Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA observed several residents watching TV in living room and one resident flipping through magazines on the dining room table

· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Resident Rooms 1 - 4: All contained the required furnishings, lighting and linens. Bedrooms were observed to be clean with plenty of closet space. Bedroom #1 is the only bedroom that is shared.

· Bathrooms: Shared client bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 114.9 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 was observed to be clean and water temperature was measured at 111.9 degrees F.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CON CARINO INC.
FACILITY NUMBER: 197604439
VISIT DATE: 06/13/2023
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· Centrally Stored Medications: LPA observed cabinet located in hallway to be locked and inaccessible to residents. LPA reviewed 6 client medications and Medication Administration Record (MAR).

· Backyard: Clean and free from hazards. LPA observed plenty of seating and shade. No large bodies of water were observed.

LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Administrator certificate was observed for Chris Gutierrez with an expiration date of 08/15/24. Last fire drill was conducted on 05/22/23 and last earthquake drill was conducted on 05/22/23. First Aid kit was inspected. 6 out of 6 clients records were reviewed. LPA discovered R1 did not have TB test updated on Physicians Report prior to being admitted to this facility. LPA was able to verify R1 did complete a TB test several days after leaving former facility. Technical violation is being cited. Staff files were reviewed.

No deficiencies are being cited during visit. Exit interview was conducted with Linda Morales and a copy of this report was provided via email due to printer problems.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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