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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603200
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:47:26 PM

Document Has Been Signed on 08/08/2024 12:47 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:PRISTINE GUEST HOMEFACILITY NUMBER:
198603200
ADMINISTRATOR/
DIRECTOR:		BUAN, ALAN ROBERTFACILITY TYPE:
740
ADDRESS:1026 HEDGEPATH AVETELEPHONE:
(626) 295-2479
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 6CENSUS: 5DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Alan BuanTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with administrator Alan Buan and the purpose of the visit was explained.

The following CARE tools domains were utilized during the inspection.

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan.

Physical Plant/Environment Safety: The facility is a single-story building located in a residential area with four (4) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, kitchen, dining area, living room, laundry room, front yard, backyard, and attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were locked and inaccessible to residents in care. The facility has one (1) fully charged fire extinguisher and a fire pull alarm. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.



Operational Requirements: The facility has a Dementia Waiver in place. A Hospice Waiver for up to (3) Residents is approved. A fire clearance for 6 non-ambulatory adults 60 and over. Required Liability Insurance is in place. A surety bond is not applicable. Facility does not handle resident's money.

Incident Medical and Dental: LPA reviewed medications for five (5) Residents. 30-day supply of resident medications were observed. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident.

Continued on LIC 809-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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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: PRISTINE GUEST HOME
FACILITY NUMBER: 198603200
VISIT DATE: 08/08/2024
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Staffing: Sufficient caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expired but currently pending renewal. Personnel files were reviewed. LPA reviewed a total of (5) Staff fIles including the administrator. LPA observed required documents for each. Proof of staff training was reviewed. Current 1st Aid/CPR records are current.

Resident Records/Incident Reports: A total of five (5) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information forms were observed.



Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Modified diets in place. \

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today.
There are currently four (4) Dementia residents 60 years and older residing in the facility.

Residents with Special Health Needs: One (1) resident receives home health services. Postural support observed. (5) residents with half bed rails. No residents are on hospice. No residents have prohibited health conditions. No residents have restricted health conditions.


No deficiencies are being cited on todays visit. Exit Interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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