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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602955
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:21:37 PM

Document Has Been Signed on 11/27/2023 03:21 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: 6DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Ralph Estanislao- AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Caregiver, Angela Gavilanes, and explained the purpose for the visit. Administrator, Ralph Estanislao, arrived shortly after and assisted with the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Ralph, observed the facility food supplies, reviewed (6) resident medications, (6) resident files, (3) staff files, and conducted interviews with (3) staff and attempted interviews with (6) residents. The facility is a two-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. It has an approved dementia care plan. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden, and has a hospice waiver approved for (4). There is currently (1) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file.
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. Upon arrival to the facility, LPA was unable to enter the property and observed the front gate locked. LPA Maldonado had to ring the doorbell and a caregiver had to open the gate by key to allow LPA entry. LPA asked Ralph the reason for the locked gate. He stated it was due to safety precautions as there are transients near the home. The facility does not have a fire clearance approved for locked perimeters. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and storage space. (5) of (6) residents' beds were observed to have bed rails. However, Resident# 4 (R4) did not have a written physician's order indicating the need for them, in their file. All other residents had proper written physician's orders for the bed rails in their files. The facility is required to have auditory devices. LPA Maldonado observed the auditory device in room# 3 to be inoperable. Cameras were observed operating in common areas of the home. No cameras were observed in private areas/resident rooms.
(Report continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2023
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 10
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: 11/27/2023
NARRATIVE
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Resident bathrooms were observed to have a shower, toilet, and wash basin. The showers accommodate non-ambulatory residents and have the required grab-bars and non-skid mats. The hot water was tested and measured at 126*F, which is not in compliance. The food supplies was observed and had the required 2-day perishables and 7-day non-perishables. Emergency food and water was also available. Fire extinguishers were observed throughout the facility, with current inspections and were fully charged. The first aid kit was observed to be complete and a current first aid manual was available. All sharps, cleaning supplies and toxins were observed locked and inaccessible to residents in care. A fire place was observed in the living room, covered by a screen and inaccessible. The smoke/carbon monoxide detectors were tested, were interconnected and operational at the time of the visit. A fish pond was observed in the back yard. It had water, but it is completely fenced off, inaccessible to residents in care. The last fire drill was conducted on 5/21/23, which is not in compliance. During the file review, it was discovered that Staff# 3's (S3) file was missing proof of the required annual training, and CPR/First Aid certification expired on 05/2020. The file for Staff# 2 (S2) was also missing a health screening. LPA also discovered that the Administrator did not have a complete file at the facility available to review/audit. After review of resident files, it was discovered that Residents# 1, 4 and 5 (R1, R4, and R5) do not have an updated medical assessment as they are required to, due to cognitive impairment. It was also discovered that (5) of (6) residents do not have an Appraisal/Needs and Services Plan on file. After review of resident medications, it was discovered that R2, R5, and R6 were missing medications that have not yet been refilled. It was also discovered that R2 and R4 had medications and vitamins that are being administered to them without physician's orders on file.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit and will be cited on the LIC809-D.
Additionally, immediate civil penalties were assessed in the amount of $500, due to a Fire Clearance Violation.

An exit interview was conducted with Administrator, Ralph Estanislao, and a copy of the report and appeal rights were provided and discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in (2) of (3) staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will submit health screening records for S1 and S2, to LPA via 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in (1) of (3) staff files not available for Licensing to review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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2
3
4
Licensee will ensure that a complete file for Administrator is available at the facility at all times. A copy of the Adminstrator file will be emailed to LPA by POC due date.
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
1
2
3
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Based on record review, the licensee did not comply with the section cited above in (1) of (3) staff had no proof of required annual training on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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2
3
4
Licensee will submit proof of required annual training for S3 to LPA via email 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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (5) of (6) residents do not have a Needs and Services Plan on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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2
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Licensee will complete a Needs and Services plan for R1-R4 and R6 and submit to LPA via email by the POC due date.
Type B
Section Cited
CCR
87465(c)(1)
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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in (2) of (6) residents with medications being administered without a written prescription for it, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will obtain written orders for medications for R2 and R4 and email them to LPA 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in (3) of (6) residents medications have not been refilled and are not being given as prescribed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will obtain medication needed for R2, R5, and R6 and will submit refill orders to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in the last fire drill conducted on 05/21/23 and is past the quarterly requirement, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will conduct a new fire drill and submit proof to LPA via 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in R4 with no written orders for bed rails, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will obtain a written physician's order indicating the need for bedrails for R4. Will submit to LPA via email by POC due date.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in (3) of (4) residents with dementia do not have an updated medical assessment or appraisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will obtain an updated medical assessment and appraisal for R1, R4, and R5. A copy will be submitted to LPA via 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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 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: CARINDALE RESIDENTIAL CARE
FACILITY NUMBER: 198602955

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above in the auditory device in room#4 was inoperable, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
1
2
3
4
Licensee will install a new auditory device in room#4. A copy of the purchase receipt and picture of installed device will be submitted to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 at 02:36 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: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in the perimeter fence gates locked under key without proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
1
2
3
4
Licensee unlocked the perimeter gates immediately. This deficiency has been cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 11/27/2023 03:21 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/27/2023 at 03:08 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: 11/27/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the water temperature measuring at 126*F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
1
2
3
4
Licensee will adjust the water and complete a water log for the following 5 days. Will submit to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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