<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606747
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:13:00 PM

Document Has Been Signed on 11/04/2022 04:13 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:SAN DIMAS ADVENTIST HOME CAREFACILITY NUMBER:
197606747
ADMINISTRATOR:JASAIEL DE LEONFACILITY TYPE:
740
ADDRESS:1136 N. SAN DIMAS AVENUETELEPHONE:
(909) 971-9769
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 5DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jasaiel De Leon- LicenseeTIME COMPLETED:
04:30 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) V. Maldonado made an unannounced visit to the facility for the purpose of conducting a required annual inspection using the Infection Control Evaluation Tool. LPA Maldonado met with the licensee Jasaiel De Leon and explained the purpose for the visit. LPA conducted a tour of he physical plant with the licensee, observed COVID-19 procedures, food supply, reviewed residents' medications, and resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

The facility is a one-story home, located in a residential area and is licensed to serve (6) residents, ages 60 and over. The license is approved for (6) non-ambulatory residents, approved hospice waiver for (1), and approved dementia care plan. The home consists of (4) resident bedrooms, (2) bathrooms, kitchen, dining room, living room, laundry room, a shaded patio in the backyard, and a detached garage. (1) resident bedroom is shared and (3) are private. LPA observed all resident bedrooms to have the required furniture, linens, and closets with additional storage space. Additional clean linens were observed in a hallway closet and were observed to be in good condition. All entrances/exits were observed to have operating auditory devices during the visit. All walkways and pathways were observed to be free of obstructions and hazards. The food supplies in the facility was observed to be a variety of nutritious foods. The required 2-day of perishables and 7-day non-perishables foods were observed in the kitchen and outside refrigerators, as well as in the pantry. All cleaning supplies/toxins were observed inaccessible in a cabinet in the locked laundry room and all sharps were locked and inaccessible in a kitchen drawer, across from the refrigerator. A fire extinguisher was observed in the kitchen to have a recent inspection and be fully charged. LPA observed the bathrooms in the home to have a toilet, shower, and wash basin- all in good repair and operational. The water temperature was tested and measured at 116.8*F in bathroom#1 and 115.3*F in bathroom#2.

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 4
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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747
VISIT DATE: 11/04/2022
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
Smoke/carbon monoxide detectors were observed throughout the facility and were operational upon testing. The First Aid Kit was observed to have the required items and First Aid Manual.

LPA did not observe COVID-19 signange posted throughout the facility to promote mask wearing, cough/sneeze etiquette, and social distancing. A sufficient 30-day supply of Personal Protective Equipment (PPE) was observed in the garage and throughout the facility, accessible to residents, staff, and visitors. There is a central entry point designated for temperature/symptom screening. All hand washing stations were observed to have sufficient soap and paper towels.

LPA reviewed 5 resident files. Files were complete with health screenings and updated emergency contact information. During the resident file review, it was discovered that 2 residents with dementia did not have updated Physician's Reports, as required. LPA also reviewed 3 staff files to confirm health screenings, fingerprint clearances and required training certification. LPA reviewed 5 residents' medications. Medications are documented properly and given as prescribed. During the medication review, it was discovered that 2 of 5 resident medications did not have proper labels on the bottles, although they are prescribed.

Per California Code of Regulations and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D report.

An exit interview was conducted with licensee Jasaiel De Leon and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/04/2022 04:13 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/04/2022 at 03:41 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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e)For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication...
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 5 resident medications were not properly labeled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2022
Plan of Correction
1
2
3
4
The licensee will place a label on 3 medications that were observed to not have a label for 2 of 5 residents. A picture of the proper labels on medications and medication records will be provided to LPA via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/04/2022 04:13 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/04/2022 at 03:47 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: SAN DIMAS ADVENTIST HOME CARE
FACILITY NUMBER: 197606747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)
87705 Care of Persons with Dementia
(5)Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 residents with dementia did not have an annual medical assessment and reappraisal done, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2022
Plan of Correction
1
2
3
4
Licensee will obtain a medical assessment and reappraisal done for 2 residents with dementia and will provide copies of Physician's Report and Appraisal to LPA via email by POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4