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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607333
Report Date: 06/01/2021
Date Signed: 06/01/2021 05:25:12 PM

Document Has Been Signed on 06/01/2021 05:25 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:GLENDALE GOLDEN YEARS HOMEFACILITY NUMBER:
197607333
ADMINISTRATOR:AURELIO TRILLANAFACILITY TYPE:
740
ADDRESS:1502 LYNGLEN DR.TELEPHONE:
(818) 551-9421
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY: 6CENSUS: 4DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Aurelio Trillana, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Linda Almaraz and Alberto Lopez conducted an annual required visit. LPA's met with Administrator Aurelio Trillana and his wife Maria Trillana and explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is approved.

The facility is a 4 bedrooms 3 bathroom home located in a residential neighborhood. Facility has a main entry point for screening. All 4 clients bedrooms were toured. Each bedroom has a chair, bed, linen, dresser, light, sufficient closet space and required furniture and equipment. All bathrooms were toured and the toilets, hand washing and shower/bathtub are safe and sanitary. The food in the kitchen has sufficient supply of 2 days perishable and 7 days non-perishable. All the appliances are clean and working properly. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records.

The hot water temperature in the bathrooms measured between 131.9 and 132 degrees F. Medication logs had several discrepancies for the months of February and March 2021, and partial recording for April. No medication administered was recorded for May 2021. They also had no records from April 2020-August 2020 and partial recording of medication administered for September and October of 2020.

Deficiencies cited under California Code of Regulations Title 22

An exit Interview was conducted with the Administrator and a hardcopy was provided. Appeal Rights was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Linda M Almaraz
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2021
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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Document Has Been Signed on 06/01/2021 05:25 PM - It Cannot Be Edited


Created By: Linda M Almaraz On 06/01/2021 at 12:42 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: GLENDALE GOLDEN YEARS HOME
FACILITY NUMBER: 197607333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)


This requirement is not met as evidenced by: Medication Administration Record (MAR) log was not completed since April 2020 and had partial recording for the months of September and October of 2020, and April of 2021.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents medication records reviewed, which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 06/02/2021
Plan of Correction
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Licensee shall have staff trained by a pharmacy or nurse on proper administration and accurate record keeping for medication. Licensee shall conduct training by POC due date and will send proof to LPA via email or fax.
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPAs and staff member Reynato Encinares checked water temperatures for two bathrooms. Both bathrooms had a reading above 131.0 degree F.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2out of 2 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2021
Plan of Correction
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Licensee shall adjust water temperatures for the whole facility to be within regulation limits of 105-120 degree F. Licensing will send proof of correction to LPA by POC due date.
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:Linda M Almaraz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2021


LIC809 (FAS) - (06/04)
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