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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601706
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:14:06 PM

Document Has Been Signed on 11/19/2021 01:14 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:BALDWIN GRACIOUS LIVINGFACILITY NUMBER:
198601706
ADMINISTRATOR:DELFIN M. PEGOLLOFACILITY TYPE:
740
ADDRESS:14218 ROCKENBACH STTELEPHONE:
(626) 252-4803
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 6CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Hermie Pegollo; Facility ManagerTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Facility Manager Hermie Pegollo and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Facility Manager toured the home and inspected (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 66.3F which is below the required 105F - 120F degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon Monoxide detectors are intertwined with the smoke detectors and were operable. There are (3) fire extinguisher located throughout the facility which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked under the sink and are inaccessible to residents. First Aid kits were fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (4) out of the (4) resident medications were reviewed. Medications are centrally stored in a cabinet in the kitchen. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
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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Document Has Been Signed on 11/19/2021 01:14 PM - It Cannot Be Edited


Created By: David Sicairos On 11/19/2021 at 11:31 AM
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: BALDWIN GRACIOUS LIVING

FACILITY NUMBER: 198601706

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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During physical plant tour of the facility, Facility Manager informed LPA that facility is currently repairing the hot water. Water temperature in Bathroom#1 read at 66.3F during visit. This poses a potential a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2021
Plan of Correction
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Licensee to enure facility water temperature used by residents shall attain a temperature of not less than 105F and not more than 120F at all times. Licensee to submit water log to LPA by POC date demonstrating water temperature at facility meets Title 22 Regulations.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:David Sicairos
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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