197606540-2-3-2025-28-AS-KRAZ-DDJVEY-20250203152307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606540
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:23:56 PM

Document Has Been Signed on 02/03/2025 03:23 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:	LA VERNE MANOR		FACILITY NUMBER:	197606540
ADMINISTRATOR/ DIRECTOR:	JOHN MICHAEL TANADA		FACILITY TYPE:	740
ADDRESS:	2555 6TH STREET		TELEPHONE:	(909) 593-4567
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY: 80		CENSUS: 37	DATE:	02/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:01 AM
MET WITH:	Administrator Michael Tanada		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 2/3/2025 and was greeted by Administrator Michael Tanada. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms inspected contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Facility has video surveillance inside common areas.

Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed an activities schedule for the month of February 2025 posted. The facility does not have a full-time staff member, responsible to organize, conduct and evaluate planned activities. LPA Ramirez will issue a Type B deficiency based on this observation.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 1/3/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry.

See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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 5

Document Has Been Signed on 02/03/2025 03:23 PM - It Cannot Be Edited

Created By: Kimberly Ramirez On 02/03/2025 at 01:28 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: LA VERNE MANOR	FACILITY NUMBER: 197606540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(f)

Planned Activities

(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the facility does not employ a full-time staff member who is responsible to organize, conduct and evaluate planned activities, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Licensee will certify plan to address how the facility plans to become compliant with this regulation by 2/17/25. Licensee will email plan by 2/17/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Kimberly Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: LA VERNE MANOR	FACILITY NUMBER: 197606540
	VISIT DATE: 02/03/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Auditory devices were observed to be in working order.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for John Michael Tanada expires 9/22/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for fifty (50) ambulatory and thirty (30) non-ambulatories. Rooms #1, thru #19, #24, #30 and #38 are cleared for non-ambulatory residents. This facility may retain no more than eight (8) hospice residents. There were zero (0) residents under hospice care during inspection.

Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

One (1) deficiency was observed and cited during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 9102, and appeals rights was provided via email.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5