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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801279
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:13:00 PM

Document Has Been Signed on 09/24/2021 05:13 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:LEANING PINE, THEFACILITY NUMBER:
197801279
ADMINISTRATOR:VILLAFLOR, ELNA C.FACILITY TYPE:
740
ADDRESS:1809 LEANING PINE DRIVETELEPHONE:
(909) 396-4675
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Elna Villaflor, administratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Elna Villaflor and discussed the purpose of today's visit. This single-story home contains four (4) bedrooms, two (2) bathrooms, caregivers quarters, living room, kitchen, dining area, backyard, and attached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, PPE, screening logs, and sign-in sheet.
  • COVID-19 signage was placed in several areas of the facility.
  • Facility maintained a 30-day supply of PPE.
  • There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured and were within the required 105-120 degrees F.
  • Each room contained required furniture including bed, dresser, night stand, lamp and chair.
  • Each bed did not contain all of the required linen including mattress cover, fitted sheet, flat sheet, blanket and comforter.
  • Bathrooms contained hygiene supplies including liquid soap, paper towels, and toilet paper.
  • Medications were locked, central stored, and given as prescribed. Facility maintained 30-day supply.
  • Staff did not wear face masks consistently throughout the shift and group activities were not spaced to encourage physical distancing.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • A fire extinguisher was observed to be fully charged and last serviced April 2021.
  • Client files were inspected and emergency contact information and physician's reports were up-to-date.
  • All staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. Administrator certificate expires 6/2022.
  • The outdoor passageways were obstructed with large items needing to be discarded.
Pursuant to Title 22, deficiencies were cited on attached 809D. Technical advisories issued on separate LIC9102. An exit interview was conducted and a copy of this report were provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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 09/24/2021 05:13 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/24/2021 at 04:09 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: LEANING PINE, THE
FACILITY NUMBER: 197801279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for 3 screens which poses a potential health, safety or personal rights risk to persons in care. One screen sliding door had an approx. 6 inch tear. Two client bedrooms did not contain screens.
POC Due Date: 10/15/2021
Plan of Correction
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The administrator stated that she will have the screens replaced and will provide pictures to CCL by POC due date.
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 5 out of 5 beds which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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The administrator stated that she will provide all required linens for bed and send a receipt for purchased items to CCL 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:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/24/2021 05:13 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 09/24/2021 at 04:09 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: LEANING PINE, THE
FACILITY NUMBER: 197801279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the outdoor passageways which contained items meant to be discarded including rolling medical beds, wood pieces, and plastic bottles which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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The administrator stated that she will have the items removed and will send a picture of the cleared areas by POC due date.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5