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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602908
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:34:55 PM

Document Has Been Signed on 03/09/2023 04:34 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. CECILIA'S SENIOR HOME IIFACILITY NUMBER:
198602908
ADMINISTRATOR:VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:172 S. COUNTRY CLUB ROADTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
03/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Briana Mcgee TIME COMPLETED:
04:46 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Staff, Marivic Vigilla who allowed entry. The purpose for the visit was explained. Briana Mcgee, cousin of Licensee was given approval to assist LPA with visit. LPA toured physical plant with Staff.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 4 non-ambulatory and 2 ambulatory residents residing at the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guest.
Physical Plant & Environment Safety: There are no pool or bodies of water at the premises. There are 4 resident rooms bedrooms and one staff bedroom, 3 bathrooms, living room, family room, dining room, kitchen, and an unattached garage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 111.2 -111.9 degrees F which is within required range of 105-120 degrees.
Due to time constraints. LPA will return to complete inspection and another day.

No deficiencies cited at this time. Report and appeal rights provided to Brianna Mcgee

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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