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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601619
Report Date: 03/03/2022
Date Signed: 11/03/2022 10:37:29 AM

Document Has Been Signed on 11/03/2022 10:37 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. DANIEL'S ELDERCARE, INCFACILITY NUMBER:
198601619
ADMINISTRATOR:DEBORAH DAVISFACILITY TYPE:
740
ADDRESS:1760 BRIDGEPORT AVETELEPHONE:
(909) 624-1093
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Deborah Davis, Administrator TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Maribel Kessel, Caregiver and Administrator Deborah Davis arrived a short time later and LPA explained the purpose of the visit. Administrator certificate expires 1/15/2023 Last fire drill was on 01/24/2022

Structure:
The Facility is a single storey building in a residential area with 6 resident bedrooms and 1 staff bedroom, there’s 2 dining rooms, 4 full bathrooms, a kitchen. A laundry room, a family room and TV room area. There is a large garden area on the back premises with tables and chairs and shade. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction. Facility has hospice waiver for 6 residents. Currently there is 1 hospice resident.

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between 105 – 120 degrees F which is within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Facility has one designated isolation room.
· Six client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Six client rooms were equipped with alcohol based hand sanitizer.
· Five (5) centrally stored client medication records were reviewed.
· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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: ST. DANIEL'S ELDERCARE, INC
FACILITY NUMBER: 198601619
VISIT DATE: 03/03/2022
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· Staff and resident files were not reviewed during today's visit.
· No deficiencies were observed during today’s visit.
· Exit interview was conducted with Administrator Deborah Davis. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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