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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320051
Report Date: 11/19/2021
Date Signed: 11/24/2021 11:12:21 AM

Document Has Been Signed on 11/24/2021 11:12 AM - 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PEPPER TREE ASSISTED LIVINGFACILITY NUMBER:
198320051
ADMINISTRATOR:KLEIN, STEPHANIEFACILITY TYPE:
740
ADDRESS:2353 251ST STREETTELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 5DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mila , House ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analysts Ana Soto and Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPAs met with caregiver staff Mila Santos, House Manager; the facility is clear of Covid-19 infection. LPAs explained the purpose of todays visit. The facility is licensed for six (6) non-ambulatory residents over the age of 60, hospice waiver approved for four (4).

LPA and staff toured the inside and outside grounds of the facility. The one story residential house consists of five (5) resident bedrooms, four (4) resident bathrooms, dining area, and kitchen, laundry area in the garage, and a shaded patio area, backyard. During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA observed a sanitizing station outside near the facility entrance; PPE supplies are readily available to staff, and an additional 30-60 day supply of PPE was observed in the garage area. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the shaded backyard or front patio area. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility.

Bedrooms were inspected, Beds and bedding supplies were in good condition, adequate lighting provided. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, the water temperature measured at 109.6 degrees F in bathroom. Comfortable temperature was maintained in the facility.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051
VISIT DATE: 11/19/2021
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One (1)Carbon Monoxide and interconnected Smoke Detectors were tested, and in operating condition. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged and accessible.. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

LPA checked staff and resident file and reviewed medication. On 11/19/2021 at approximately 10:42am LPA observed over the counter medication: Calcium, D3, C, Multi-50+ vitamins, aspirin, and allegra for Resident#1 (R1), medication bottles didn’t have prescription label.

Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No bodies of water present.

Advisory Notes with technical assistance were issued:

1. Ensure all staff are fit tested for respirators.

2. CCLD provider information notices (PINS) shall be posted and available to residents/ staff.

3. Facility shall take and document residents & staff temperature & screen for covid symptoms.

4. Isolation room postings shall be available in the event of a Covid-19 positive case.

A deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to facility representative, _Mila Santos.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2021 11:12 AM - It Cannot Be Edited


Created By: Ana Soto On 11/19/2021 at 02:51 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PEPPER TREE ASSISTED LIVING
FACILITY NUMBER: 198320051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87465(h)(3) (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills.

POC Due Date: 12/03/2021
Plan of Correction
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Administrator to have pharmacy generate labels for the for mention medicines on the report provided. Administrator to send photo via email, fax, or text when labels received to LPA Soto 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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
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