<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601637
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:59:05 PM

Document Has Been Signed on 02/06/2025 04:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. DANIEL'S HOME FOR THE ELDERLY II, INC.FACILITY NUMBER:
198601637
ADMINISTRATOR/
DIRECTOR:		DEBORAH DAVISFACILITY TYPE:
740
ADDRESS:2315 NAVARRO DRIVETELEPHONE:
(909) 624-1286
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 6CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Administrator Deborah DavisTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 2/6/2025 and was greeted by Caregiver Lorraine Yee. Administrator Deborah Davis arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Resident bedroom#4 is currently unoccupied, and shared resident bedroom#2 currently only has one (1) resident. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip mat in showers. Shower was observed to be wheelchair accessible. LPA Ramirez observed the facility den was converted into a resident room. The licensee must obtain prior approval from this licensing agency to change plan of operation, including facility sketch. LPA Ramirez will issue type B violation based on observation.

Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 1/3/2025 and 11/3/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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 HOME FOR THE ELDERLY II, INC.
FACILITY NUMBER: 198601637
VISIT DATE: 02/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Residents with Special Needs: LPA Ramirez observed a pool with a locked gate around it. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Auditory devices were observed to be in working order.

Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Deborah Davis was received by Administrator Certification Bureau and is pending. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for five (5) non-ambulatory and one (1) bedridden. During resident record review, LPA Ramirez observed Resident#1’s (R1), Resident#2’s (R2), Resident#4’s (R4), physician report indicated they are bedridden. The facility fire clearance is approved for one (1) bedridden only. LPA Ramirez will issue a type A violation and assess a $500 civil penalty. This facility may retain no more than six (6) hospice residents. There were three (3) residents under hospice care during inspection.

Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.

Two (2) violations were observed and cited during this annual inspection. One (1) civil penalty was assessed during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 421IM, and appeals rights was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/06/2025 04:59 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 02/06/2025 at 01:27 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: ST. DANIEL'S HOME FOR THE ELDERLY II, INC.
FACILITY NUMBER: 198601637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, 3 out of 4 residents have a LIC 602 indicating BEDRIDDEN, the facility has an approved fire clearance for 1 bedridden, the licensee did not comply with the section cited above in 3 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
1
2
3
4
Licensee agreed to obtain new LIC 602 with corrected ambulatory status or provide proof of application for new fire clearance by 2/14/2025. Licensee will certify plan via email to LPA Ramirez by 2/7/25. Licensee will notify fire department of bedridden residents within 48hrs.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/06/2025 04:59 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 02/06/2025 at 01:45 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: ST. DANIEL'S HOME FOR THE ELDERLY II, INC.
FACILITY NUMBER: 198601637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87208(a)(7)(A)
87208 Plan of Operation (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)
This requirement is not met as evidenced by:
Facility den was designated into resident bedroom#5 without prior approval.
Deficient Practice Statement
1
2
3
4
Based on observation and record review, plan of operation such as facility sketch and floor plan was changed prior to this licensing agency's approval, the licensee did not comply with the section cited above in 1 out of 4 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
1
2
3
4
Licensee will operate in accordance with approved plan of operation. Licensee will relocate R1 into an approved resident room within the facility.

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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4