198601619-2-11-2023-28-AS-KRAZ-CNXR4H-20230211114133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601619
Report Date: 02/11/2023
Date Signed: 02/11/2023 11:41:48 AM

Document Has Been Signed on 02/11/2023 11:41 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, INC		FACILITY NUMBER:	198601619
ADMINISTRATOR:	DEBORAH DAVIS		FACILITY TYPE:	740
ADDRESS:	1760 BRIDGEPORT AVE		TELEPHONE:	(909) 624-1093
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 6		CENSUS: 6	DATE:	02/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:16 AM
MET WITH:	Administrator Deborah Davis		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/11/2023 at 8:17 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. At 8:32 am Administrator Deborah Davis later arrived to lead tour. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for six (6) hospice residents. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), and copy of liability insurance.

LPA OBSERVATIONS: Tour began at at 8:45 am and was led by Administrator Davis. The Facility is a single story building in a residential area with six (6) resident bedrooms, one (1) staff bedroom, two (2) dining rooms, four (4) full bathrooms, kitchen, family room, TV room area, laundry room and attached three car garage.

· Front Yard: Was clean and well maintained. A pool was observed to be clean and water appeared to be clear; pool is gated and inaccessible to residents.

· Kitchen/Pantry: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 115.5 degrees F. Signs promoting hand washing and social distancing were observed. Sharps were secured in cabinet to the left of kitchen sink and inaccessible to residents. Cleaning solutions and disinfectants were observed to be locked in cabinet directly under kitchen sink and inaccessible to residents. Pantry contained emergency water supply.

· Dining Room/Family Room/TV Room: Dining rooms were observed to be clean and contained tables and chairs. Family room/TV room area had 7 recliners and additional seating for residents and guests. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area.

· Linen Closet: Contained plenty of linens, towels, and hygiene products.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. DANIEL'S ELDERCARE, INC	FACILITY NUMBER: 198601619
	VISIT DATE: 02/11/2023

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·Resident Rooms 1 - 6: All contained the required furnishings, linens and were observed to be clean. Resident Bedroom #4 ceiling contained bubbling, peeling and two 6 x 6 slits that exposed dry wall. The bubbling and slits were observed to be brown in color. LPA observed spider webbed pattern of cracks surrounding this area. Per Administrator Davis, rain caused damage to the ceiling around Christmas but did not cause leaking in the resident room. Administrator Davis stated a roofer has already been out to inspect the roof and tarped the roof area to prevent further damage. Repair to roof is set to begin in three weeks according to Administrator Davis.

· Bathrooms: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Grab bars were observed near toilet and shower. Water temperature in this bathroom was measured at 118.6 degrees F which is in the required 105 – 120 degrees F. LPA observed middle light bulb near bathroom sink to be out. Shared Bathroom #2 water temperature was measured at 111.4 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilet and shower. Private resident bathroom located in resident bedroom #4 was observed to be clean and contained grab bars and non-slip mats in shower. Two (2) lights bulbs were observed to be out in near sink.

· Centrally Stored Medications: Is located near hallway and was observed to secured and inaccessible to residents. LPA reviewed 6 out of 6 resident medications. First aid kit was observed and inspected.

· Attached Garage: LPA observed PPE supplies and was inaccessible to residents.

· Laundry Room: Was inaccessible to residents and laundry detergent was locked in cabinet above washer and dryer.

Administrator certificate was observed for Deborah Davis with an expiration date: 01/15/23 and was renewed and pending. Last fire drill was conducted on 01/22/2023. LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit. Several fire extinguishers were observed in the facility and were fully charged.

No deficiencies were cited during visit. Two (2) technical violations noted and advisory. Exit interview was conducted with Administrator Davis and a copy of this report was left.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

LIC809 (FAS) - (06/04)

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