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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608336
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:54:43 PM

Document Has Been Signed on 08/25/2021 04:54 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:GREENPARK MANORFACILITY NUMBER:
197608336
ADMINISTRATOR:GLADYS PERVEZFACILITY TYPE:
740
ADDRESS:903 N. GREENPARK AVENUETELEPHONE:
(626) 859-7513
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY: 6CENSUS: 6DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gladys PervezTIME COMPLETED:
05:00 PM
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On 8/25/21 at 12:45 p.m. Licensing Program Analysts Nina Galarza and Nune Margaryan arrived at the facility to conduct an unnanounced annual visit. LPAs met with Teresita Roda and later met with administrator Gladys Pervez and stated the purpose of the visit. LPAs observed COVID informational, hand washing protocol postings outside the facility and throughout the facility. LPAs were screened for COVID symptoms and temperature was taken by staff.

The facility is licensed to serve one (1) Bedridden and five (5) Non-Ambulatory residents (ages 60 and above). The facility has an approved Hospice Waiver for two residents on file. Currently, there are six (6) residents in placement.

The facility is a single story home located in a residential neighborhood. LPA observed the facility to have four (4) resident bedrooms, 2 bathrooms, living room, dining room, kitchen, garage equipped with a laundry area and an indoor/outdoor activity area. Bathrooms are clean and operational with grab bars and non-skid surface mats in place. The hot water temperature measured at 114 degrees Fahrenheit and 117.2 degrees Fahrenheit. Adequate linen and personal hygiene supplies. LPAs observed 2 days worth of perishable and 7 days worth of nonperishable foods for all clients. Smoke and carbon monoxide detectors are dual/hardwired and operable.

All mandated documents are posted in a prominent place. The outdoor activity area is free of visible hazards and debris. There is shaded patio areas with ample seating in the rear. The trash cans have covered lids. Staff and resident records have required documentation. All exit doors are equipped with auditory device alarms.

CONTINUED 809-C
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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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: GREENPARK MANOR
FACILITY NUMBER: 197608336
VISIT DATE: 08/25/2021
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The following deficiencies were observed at time of visit:
  • R1 was prescribed Purelax powder, 1 Capful as needed, but was not listed on residents Medication Administration Record (MAR)
  • R2 was missing Bezonate, 100 mg; 1-2 cups for cough.
  • R3 medication was not labeled for; Acetaminophen 325 mg, Milk of Magnesia, Aspirin 81 mg, and Antacid Liquid
  • R4 medication was not labeled; Melatonin 10 mg

Deficiencies cited per California Code of Regulations.

Exit interview conducted, a copy of appeal rights and report given to administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nina Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2021 04:54 PM - It Cannot Be Edited


Created By: Nina Galarza On 08/25/2021 at 04:06 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: GREENPARK MANOR
FACILITY NUMBER: 197608336

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
(h)The following requirements shall apply to medications which are centrally stored: (4) all centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2021
Plan of Correction
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Administrator will provide picture proof that medication for R3 medication is labeled for; Acetaminophen 325 mg, Milk of Magnesia, Aspirin 81 mg, and Antacid Liquid and R4 medication is labeled; Melatonin 10 mg via email to LPA. Adminisrator will provide picture proof that R2 medication, Bezonate 100 mg was obtained via email to LPA. Administrator corrected Medication Administration Record to include PURELAX POWDER for R1 at time of visit, further action not needed. Administrator will provide proof of training for medication administration by pharmacy or authorized trainer to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nina Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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