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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602908
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:31:46 PM

Document Has Been Signed on 03/16/2023 03:31 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:
03/16/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Tiffany Vander Poorten TIME COMPLETED:
03:49 PM
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LPA made subsequnt visit to complete annual inspection that was started on March 9, 2023 LPA met with Administrator Tiffany Vander Poorton and explained the purpose of the visit.

Staffing: There appears to be sufficient staffing at the facility. The administrator's (Tiffany Vander Poorten) certificate has expired. Administrator has submitted for renewal on 11/21/2022 Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted during visit.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed all 6 residents' medication and observed some PRN to not have labels attached to containers.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen.

(Continued on 809C)

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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. CECILIA'S SENIOR HOME II
FACILITY NUMBER: 198602908
VISIT DATE: 03/16/2023
NARRATIVE
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During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Administrator Tiffany Vander Poorten.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/16/2023 03:31 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/16/2023 at 03:05 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. CECILIA'S SENIOR HOME II
FACILITY NUMBER: 198602908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The facility has several PRN that required labels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Administrator will obtain orders for PRN medications and labels and send proof to LPA by POC date
Deficiency Dismissed
Type B
Section Cited
CCR
87035(a)
Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Restroom by kitchen is demolished and administrator does not have permit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2023
Plan of Correction
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Licensee shall:
1. Contact City Planning Code Enforcement department and Fire Department regarding building permit.
2. Submit a written plan of correction and proof that the aforementioned items have been completed.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
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