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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602955
Report Date: 11/20/2022
Date Signed: 11/20/2022 02:02:54 PM

Document Has Been Signed on 11/20/2022 02:02 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:CARINDALE RESIDENTIAL CAREFACILITY NUMBER:
198602955
ADMINISTRATOR:NARVAEZ, JANETFACILITY TYPE:
740
ADDRESS:1342 S. BARRANCATELEPHONE:
(626) 426-1369
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 4DATE:
11/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica Torres- CaregiverTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Infection Control tool to evaluate the facility. LPA Maldonado met with Caregiver Jessica Torres and explained the purpose for the visit. Jessica called the administrator/licensee Ralph Estanislao to notify of the visit. LPA conducted a tour of the physical plant with Jessica, observed the food supplies, COVID-19 procedures, and reviewed client and staff files, and client's medications. The facility has an approved mitigation plan on file.

The facility is a two-story home located in a residential area. It is licensed to serve (6) elderly residents, ages 60 and over, of which all may be non-ambulatory and (1) may be bedridden, and has a hospice waiver approved for 2. The home consists of a living room, kitchen, dining room, (6) resident bedrooms, (1) staff room located upstairs, (2) bathrooms, (1) staff/visitor bathroom, a shaded patio in the backyard with seating, and a detached garage. LPA observed all resident bedrooms to have the required furniture, bedding, linens, sufficient lighting, closet space, and additional storage space. (2) resident bathrooms were observed to have a shower, toilet, and wash basin. LPA observed a bottle of cleaning solution underneath the bathroom sink that is located inside bedroom# 1 and a cleaning spray under the sink in the visitor/staff bathroom. The showers accommodate non-ambulatory clients and have the required grab-bars and non-skid mats. The water temperature was tested and measured between 111*F-114*F, which is in compliance. The food supplies was observed to be the required 2-day perishables and 7-day non-perishables. Several fire extinguishers were observed throughout the facility. They had current inspections and were fully charged. The first aid kit was inspected and had the required items, as well as a current first aid manual. All sharps were observed to be locked and inaccessible in a drawer in a file cabinet near the kitchen. Other cleaning supplies were locked and inaccessible, stored in a closet in bathroom# 1. All equipment was operational and in good repair. A hallway closet had additional towels and linens for clients. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit.
(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 198602955
VISIT DATE: 11/20/2022
NARRATIVE
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Medications are centrally stored in a file cabinet near the kitchen along with resident and staff files. 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 do not record, they are only used for surveillance.

LPA observed a 30-day supplies of Personal Protective Equipment (PPE) stored in the a closet inside bathroom# 1. Additional PPE was observed at the entrance of the facility- the central entry point for screening clients, staff, and visitors. PPE siganage was not observed throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing, as required by infection control practices. All hand washing stations were noted to have cloth towels in use. Staff indicated they were not aware that paper towels should still be used. Staff immediately removed the cloth towels and replaced them with paper towels.

All resident files were reviewed and had updated emergency contact information and health screenings. (2) staff files were reviewed and had Criminal Background Clearances and health screenings. There was no proof of required annual training and certifications. Staff were asked about this and stated that no training has been provided, to date. All resident medications were reviewed. (3) of (4) residents medications were not documented properly and it was found that one of R3's medication (Sertraline HCL 50mg) is not being given as prescribed. Staff stated that R3 requested to take the medication in the evening instead of morning, as is currently prescribed. Staff did not consult with R3's physician and responsible party prior to administering the medication as requested. LPA observed all residents to have full bed railings on their beds, with only (1) resident having a medical order for it, due to being on hospice. (3) residents were missing medical orders for the railings.

Per California Code of Regulations, Title 22, and Health and Safety Codes, deficiencies were observed and will be cited on the LIC809-D.

An exit interview was conducted with caregiver Jessica Torres and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/20/2022 02:02 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/20/2022 at 01:38 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 of 4 resident's medications is not being administered as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2022
Plan of Correction
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Licensee will ensure to adminster medication as prescribed and contact resident's physician and responsible party to consult on possible change in administration of medication. Licensee will provide in writing to LPA via email, the physician's order for the change in medication administration, if any, or writen order to continue medications as prescribed.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in cleaning supplies found under the bathroom sink in resident room# 1 and visitor/staff bathroom, accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2022
Plan of Correction
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Staff removed and locked items immediately accordingly.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/20/2022 02:02 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/20/2022 at 01:38 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 staff files which did not have proof of the required annual training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Licensee will ensure staff complete the required annual training and provide proof of completed training for all staff to LPA via email by the POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 3 of 4 residents did not have a written physician's order for full bed rails, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Licensee will obtain a written order from 3 of 4 resident's physician's, approving full bed rails. Proof of written order to be emailed to LPA by the 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2022


LIC809 (FAS) - (06/04)
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