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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602908
Report Date: 02/25/2025
Date Signed: 02/25/2025 02:34:08 PM

Document Has Been Signed on 02/25/2025 02:34 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. CECILIA'S SENIOR HOME IIFACILITY NUMBER:
198602908
ADMINISTRATOR/
DIRECTOR:		VANDER POORTEN, TIFFANYFACILITY TYPE:
740
ADDRESS:172 S. COUNTRY CLUB ROADTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 6DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Marivic Vigilla Care giverTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Caregiver Marivic Vigilla at approximately 12:00 PM and explained reason for visit. Administrator Tiffany Vander Poorten arrived shortly.

The facility is licensed to serve 6 non-ambulatory residents aged 60 and over with hospice approved for six. Currently, there are three (3) residents on hospice The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, family room, kitchen, 4 resident bedrooms, 1 staff bedroom,3 bathrooms, laundry area, front yard, backyard, and detached garage.



All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was 126.5, 126.5, and 125.9 degrees not within the required 105 - 120 degrees. Cleaning supplies were observed to be accessible to residents under bathroom sink. The kitchen was inspected. There is sufficient non-perishable food. It was observed that facility did not have enough two-day perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room and dining area. These areas are clean and have the required furniture.

LPA reviewed 6 resident records to confirm emergency contact is updated and residents have health screenings on file. Four staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 6 residents' medications. Medications are documented properly and given as prescribed.

Deficiencies noted. Exit interview and a copy of this report, 809D and appeal rights was provided to Administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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 3
Document Has Been Signed on 02/25/2025 02:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 02/25/2025 at 01:48 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C).

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 in three (3) out of three (3) bathrooms hot water temperature was over the 120 degree required reading which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Handy man adjusted water temperature at time of visit and Administrator will provide a weekly water log to LPA.
Bathroom #1 126.5
Bathroom #2 126.5
Bathroom #3 125.9
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 a bottle of bleach and comet cleaner were left unlocked under bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Caregiver removed items at time of visit. Administrator will go over training with staff and provide to LPA by email by POC due date.
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:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/25/2025 02:34 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 02/25/2025 at 01:48 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: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 facilty did not have enough two day perishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Administrator had food delivered at time of visit deficiency cleared at time of visit.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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