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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 02/07/2022
Date Signed: 02/07/2022 12:00:03 PM

Document Has Been Signed on 02/07/2022 12:00 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:HASTINGS RANCH HOMEFACILITY NUMBER:
198603391
ADMINISTRATOR:ESTANISLAO, RALPHFACILITY TYPE:
740
ADDRESS:1230 HASTINGS RANCH RDTELEPHONE:
(626) 351-1150
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 6DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ralph Estanislao - Administrator TIME COMPLETED:
12:15 PM
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Licensing Program Analyst(s) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food and medication review. LPA Flores met with Evelyn Mercado caregiver and explained the reason for the visit. Ralph Estanislao administrator arrived 40 minutes later.

The facility is licensed to serve 5 non-ambulatory and 1 bedridden residents over the age of 60.The facility has 5 bedrooms, 3 bathrooms, a living room, a dining room, an activity room, a kitchen and an attached garage. The outdoor facility has a front yard, a back patio.

LPA Flores conducted a tour of the facility with Evelyn Mercado caregiver at 9:15am and observed the following: Living room has a covered fire place, residents are sitting in TV area with social distancing.
Kitchen was observed and chemical cabinet under sink and sharp drawer have locks, however were not locked at the time of the visit. Medication cabinet was located to the right above the stove and locked. LPA Flores reviewed food supplies and facility has a couple of meats, rice, dressings, and sauces, some cans of vegetables, tuna, vienna sausage, and fruits as emergency food supplies which is not within the required 2 days of perishables, and 7 days of non-perishable food supplies. Administrator send staff grocery shopping, per staff grocery shopping is on Mondays. LPA observed All bedrooms have the required furniture, lighting, and bedding in each bedroom. LPA tested water temperature in bathroom #1 at 121.6 degrees F, bathroom #2 at 121.3 degrees F, bathroom #3(B3) at 128.0 degrees F, which is not within the required 105 - 120 degrees F. LPA Flores observed. LPA Flores observed PRN medication in Bedroom #4 (R4) for resident currently under hospice and actively providing. LPA Flores reviewed medication for resident #1(R1) and #2(R2). Smoke detectors were tested and in working condition, carbon monoxide detector was observed in the TV area.

LPA observed screening of visitors, staff, and residents including questionnaire. Posters were throughout the facility. Staff were observed wearing protective (PPE) were. At least 30 days worth of PPE supplies. Cleaning (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391
VISIT DATE: 02/07/2022
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and disinfecting surfaces takes place twice a day per administrator. Staff have not been Fit test for N95, administrator is scheduling appointment for testing.

Administrator Certificate was observed for Ralph Estanilao #60531027740 expiration date: 3/17/23.

Deficiencies were noted on LIC 809D, technical violation, and technical advisory given Per Title 22 Regulations, Division 6 Chapter 8.

Exit interview was conducted with Ralph Estanilao administrator and a copy of this report, LIC 809D, Technical Violation, and Technical Advisory were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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Document Has Been Signed on 02/07/2022 12:00 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/07/2022 at 11:26 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

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
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Based on observation the licensee did not comply with the section cited above in 3 out of 3 resident's bathrooms water temperature were tested at; B1 at 121.6 degrees F, B2 at 121.3 degrees F, B3 at 128.0 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2022
Plan of Correction
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Licensee will ensure water temperature is within the required 105-120 degrees F. at all times by certifying in LIC 9098 by 2/8/22. Licensee will submit a water temperature log for the next 7 days to the department by 2/14/22.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in maintain chemical solutions and sharps locked at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2022
Plan of Correction
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Licensee will ensure that all chemical solutions and sharps are locked at all times. Administrator will certify in LIC 9098 and provided in-service training to staff and will will submit to the department LIC 9098, a copy of agenda, and sign-in sheet by 2/8/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022


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