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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603124
Report Date: 05/09/2025
Date Signed: 05/09/2025 01:45:39 PM

Document Has Been Signed on 05/09/2025 01:45 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:LA POSADA IN GLENDORAFACILITY NUMBER:
198603124
ADMINISTRATOR/
DIRECTOR:		DIAZ, RAFAELFACILITY TYPE:
740
ADDRESS:1239 S SUNFLOWER AVETELEPHONE:
(562) 774-7167
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 5DATE:
05/09/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Adminstrator Paula MeraTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Elena Mallett & Luis De Leon, and Licensing Program Manager (LPM) Fernando Fierros conducted an unannounced case management visit to check facility compliance for hospice waiver request per title 22. LPAs was greeted by current Administrator Paula Mera and the purpose for today’s visit was explained.

FACILITY PHYSICAL PLANT
The facility is in a residential area. The facility is made up of five (5) client bedrooms and one (1) staff room, one (1) full bathroom for residents and one (1) full bathroom for staff, living room, dining room, laundry room, front shaded porch, and backyard, and an attached car garage. There were no body of water observed in the property. The facility has charged fire extinguishers. The building contains central air conditioning and heating.

REVIEW OF FILES
Resident record review consisted of Physicians Report for six (6) out of six (6) residents, hospice plan for four (4) out (6) residents, and medication written orders for six (6) out of (6) residents. During the visit, Administrator Paula Mera reported the passing of resident R3 the night before 5/8/2025. Administrator will send CCLD a death report for R3 and document cause of death for hospice reason care . Staff roster and staff facility association were reviewed.

Report continues on page 809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124
VISIT DATE: 05/09/2025
NARRATIVE
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Observations during facility tour with assistance of Administrator Mera.:
· Upon arrival, auditory device at main entrance was not working when door is opened. Per California Code Regulations, Title 22, facilities with dementia residents are required to have an auditory device to monitor exits on exterior doors.
· Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for clients. The facility has full bedrail orders for four (4) out of six (6) residents (R1-3, 5). Wall and floors are in good repair. Hallways were clean and free of obstructions.
· Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area.
· Toilets, showers, and water faucets are cleaned and free of mold. Restrooms were stocked and clean. The water temperature was tested and measured. A deficiency is noted for hot water in the resident restroom measured 124.1 and 124.5 for both sinks which is above the regulatory requirements in California Code of Regulation, Title 22.
· Disinfectants and sharps were observed in the garage and accessible to residents with Dementia. Therefore, a deficiency is noted on page 809D.
· Smoke detectors were observed in all bedrooms and carbon monoxide detectors was observed in the living room leading up to the bedrooms. All smoke detectors are interconnected throughout the facility. Two (2) fire extinguishers were observed at kitchen and garage and were fully charged.
· Front and back yards have shaded seating area.
· The medications are centrally stored and locked in the office.

LPAs and LPM review the request for increase of hospice waiver request with Administrator. Due to deficiencies noted during visit. The administrator will a request a hospice exception for resident who aged in place at the facility but has started hospice care. The administrator stated that facility will rescind hospice waiver request and, instead, submit the hospice exception request to the department by 05/12/25..



Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D pages. Exit interview held and a copy of the reports (809, 809C, 809D and appeal rights) along with appeal rights were provided to Administrator Paula Mera.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/09/2025 01:45 PM - It Cannot Be Edited


Created By: Luis DeLeon On 05/09/2025 at 12:52 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2025
Section Cited
CCR
87705(d)

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87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device... alert feature to monitor exits on exterior doors ... accessible to those residents who may be at risk for elopement...

This requirement is not met as evidenced by:
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Facility will fix auditory device by changing battery. Deficiency was fixed during visit and it was tested. Auditory device is now functioning properly.
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Based on LPAs observation and record review, the licensee did not comply with the section cited above in four (4) out six (6) residents with dementia who had access to the main entrance door and there was no operable auditory device which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/10/2025
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Facility will secured sharps and desinfectant in a secured room at the garage. Administrator moved sharps and desinfectant inside a locked room within the garage. Deficiency was clear at time of visit
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Based LPAs observations, the licensee did not comply with the section cited above in that the desinfectant, knives and sharps were accessible to residents with Dementia and stored in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2025 01:45 PM - It Cannot Be Edited


Created By: Luis DeLeon On 05/09/2025 at 01:00 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: LA POSADA IN GLENDORA
FACILITY NUMBER: 198603124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2025
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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Maintenance staff will regulate water temperature tank today. Facility will monitor water temperature for 3 days to ensure water temperature is within Title 22 regulation, and will send water temperature log to CCLD by 5/13/25.
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Based LPA observation, the licensee did not comply with the section cited above as hot water temperature in resident’s bathroom measured at 124.1- and 124.5-degrees F during today’s visit, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
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