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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603391
Report Date: 12/06/2022
Date Signed: 12/06/2022 03:45:14 PM

Document Has Been Signed on 12/06/2022 03:45 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
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:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Gaudeliza Evangelista - Caregiver TIME COMPLETED:
04:00 PM
NARRATIVE
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icensing 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 Gaudeliza Evangelista caregiver and explained the reason for the visit. Ralph Estanislao administrator was notified over the phone.

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, and back patio.

LPA Flores conducted a tour of the facility with Lisa Evangelista caregiver and observed the following:
Living room has a covered fire place, residents were observed sitting in TV area maintaining social distancing.
Kitchen was observed, drawer for sharps is locked. LPA observed prepared medication cups for residents under computer desk. Medication cabinet was located to the right above the stove and locked. LPA Flores reviewed food supplies and facility has at least 2 days of perishables, and 7 days of non-perishable food supplies. Garage access door was unlocked, bleach and other cleaning supplies were observed upon entry the garage around the washer and dryer area. LPA observed half open curtains and tall furniture cabinet as divider in the left corner of the garage were three (2) mattresses and a sheet maid sofa with pillows were laid and personal belongins were observed. LPA observed All bedrooms have the required furniture, lighting, and bedding in each bedroom. Bedroom #1(BR1) has a half bed rail on bed for resident #1(R1), bedroom #2(BR2) has a full length rail for resident #2(R2), bedroom #4(BR4) has a half bed rail for resident #4(R4), and bedroom #5(BR5) has a side rail on the left side of the bed for resident #6(R6). Bathrooms were observed and three (3) bathrooms are in working condition. LPA tested water temperature in bathroom #19(B1) at 116.6 degrees F, bathroom #2(B2) at 112.8 degrees F, bathroom #3(B3) at 112.6 degrees F, which is within the required 105 - 120 degrees F. LPA Flores reviewed medication and files for resident #3(R3), #4(R4), and #6(R6). LPA requested physician's order for bed rails for resident #2(R2), R4, and R6 and administrator stated there is no physician's request on file.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391
VISIT DATE: 12/06/2022
NARRATIVE
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Smoke/Carbon monoxide detectors were tested and in working condition. No large bodies of water observed. Patio has a shaded sitting area available. LPA reviewed 3 staff file, staff #2(S2) and #3(S3) do not have a TB test clearance on file.
Administrator certificate was observed for Ralph Estanislao #6053102740 exp: 3/17/2023.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Gaudeliza Evangelista Caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/06/2022 03:45 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/06/2022 at 03:06 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(1)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:

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 prepared medication in cups was observed under the computer desk, overflow medication was observed in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee will ensure staff are given proper training on medication storage and will certify on LIC 9098 copies of training and LIC 9098 are to be submit to the department by POC due date 12/7/22.
Type A
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, the licensee did not comply with the section cited above in 4 out of 6 residents have bed rails in the sides of their beds and no physician's order on file for R1, R2, R4, and R6 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee is to obtain physician's orders for bed rails for R2, R4, R6 or remove bed rails from residents beds. Administrator will submit a copy of the physician's order or pictures of the beds by POC due date 12/7/22.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/06/2022 03:45 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/06/2022 at 03:06 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 R2's bed was observed with full bed rails, R2 is not under hospice care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee is to remove full bed rails and/or request physician's order for half bed rails and submit a copy of the physician's order and a picture of proper rails by POC due date 12/7/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/06/2022 03:45 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/06/2022 at 03:06 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

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
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 staff files review did not have a TB test clearance (S2, and S3) on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2022
Plan of Correction
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Licensee will follow up with staff obtaining TB clearance and will submit a copy of the TB test clearance for S2 and S3 by POC due date 12/20/22.

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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/06/2022 03:45 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/06/2022 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: HASTINGS RANCH HOME
FACILITY NUMBER: 198603391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
87305 Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 garage has the left corner divided with furniture and curtains with mattresses laid and personal belongings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2022
Plan of Correction
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Licensee is to obtain the proper city building permits to alternate the use of the garage as a caregiver rest area/room and submit to the department or remove all items and continue to use the garage for storage, documents or pictures should be submitted to the department by POC due date 12/20/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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