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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606540
Report Date: 02/08/2022
Date Signed: 02/08/2022 10:45:02 AM

Document Has Been Signed on 02/08/2022 10:45 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:LA VERNE MANORFACILITY NUMBER:
197606540
ADMINISTRATOR:JOHN MICHAEL TANADAFACILITY TYPE:
740
ADDRESS:2555 6TH STREETTELEPHONE:
(909) 593-4567
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY: 80CENSUS: 35DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Michael Tanada, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with Administrator, Michael Tanada and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 8 hospice residents. There are currently 2 residents on hospice.

Resident bedrooms were randomly chosen for review. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.1 - 107.9 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the television room, dining room, and patio area. These areas are clean and have the required furniture. There is a sanitizer station at the entrance of the building. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. The visitation area is the lobby or outside patio.

LPA reviewed 4 resident files to confirm emergency contact is updated and residents have health screenings on file. 3 staff records were reviewed to confirm health screenings, infection control training and fingerprint clearances. LPA reviewed 4 residents' medications. Medications are documented properly and stored in a locked office.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to the Administrator.

The Administrator was notified that the annual fees are not current. The Administrator will follow-up with the licensee.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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