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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602955
Report Date: 12/09/2021
Date Signed: 01/13/2022 08:03:09 AM

Document Has Been Signed on 01/13/2022 08:03 AM - 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:CARINDALE RESIDENTIAL CAREFACILITY NUMBER:
198602955
ADMINISTRATOR:NARVAEZ, JANETFACILITY TYPE:
740
ADDRESS:1342 S. BARRANCATELEPHONE:
(626) 426-1369
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Ralph Estanislao, Lead StaffTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with lead staff, Ralph Estanislao and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 111.4 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas including the living room and dining room are clean and have the required furniture. There is a carbon monoxide detector in the hallway. The backyard has a shaded area and sitting area. There is a fish pond in the backyard that has a fence around the entire perimeter. The facility has cameras in the common areas. According to staff, the cameras are non-operational.

LPA reviewed all resident files. Resident #1 (R1) and Resident #2 (R2) are diagnosed with dementia and have physician's reports that are older than one year. Dementia residents are required to have annual physician's reports. All residents had updated emergency contact information. Staff files were reviewed. Files were complete including but not limited to first aid certificates, health screenings, proof of training, and proof of fingerprint clearance. LPA reviewed all residents' medications. Medications are documented properly and given as prescribed.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 01/13/2022 08:03 AM - It Cannot Be Edited


Created By: Tony Vasallo On 12/09/2021 at 10:56 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 6 resident files which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) and Resident #2 (R2) are diagnosed with dementia and have physician's reports on file that are over a year old.
POC Due Date: 12/30/2021
Plan of Correction
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Facility will obtain current physician's reports for both residents. Physician's reports will be submitted by 12/30/21 for review.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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