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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603473
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:54:33 AM

Document Has Been Signed on 07/12/2024 11:54 AM - 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:ST. CECILIA'S SENIOR HOME IIIFACILITY NUMBER:
198603473
ADMINISTRATOR/
DIRECTOR:		POORTEN, JOSIAH VANDERFACILITY TYPE:
740
ADDRESS:260 N. LONE HILLTELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY: 6CENSUS: 4DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Glenda PrecillasTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with licensee Tiffany Vander at approximately 9:05 AM and explained the reason for the visit. The facility cares for elderly/dementia residents and is approved to care for 6 hospice residents. There are currently 0 residents on hospice.

The 1-story facility consist of the following: Four Bedrooms, 3 Resident Bathrooms, dining room, living room, TV room, office, and patio/deck area and attached garage.

All resident bedrooms were toured. Bedrooms have the required bed, bedframe, linen, dresser, light, and closet space. During time of visit auditory devises were not working deficiency cited. Resident bathrooms were toured, and the hot water was 106-108.5 degrees which is within the required 105 - 120 degrees. Bathrooms have the required grab bars in the shower and near the toilet. The kitchen was inspected. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There is an extra freezer and refrigerator in garage filled with more food. All the appliances are clean and are operating properly. The sharp knives are located in a kitchen drawer that is inaccessible to residents. Cleaning supplies and chemicals are stored in a locked kitchen cabinet and in the garage. There is an additional refrigerator in the garage. The common areas include the living room and dining area. There is a fire extinguisher near the kitchen and another near the garage. The backyard has a shaded patio area with patio furniture. There is a pool that has a fence around the entire perimeter. There is also a fishpond that has a net on top to make the body of water inaccessible to residents.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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Document Has Been Signed on 07/12/2024 11:54 AM - It Cannot Be Edited


Created By: Christian Gutierrez On 07/12/2024 at 11:31 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: ST. CECILIA'S SENIOR HOME III
FACILITY NUMBER: 198603473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above in two (2) residents bedrooms and sliding door to back yard no auditory devices were working during tour of home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/13/2024
Plan of Correction
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Licensee fixed auditory devices during time of visit POC cleared.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ST. CECILIA'S SENIOR HOME III
FACILITY NUMBER: 198603473
VISIT DATE: 07/12/2024
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Four (4) client files were reviewed and included physicians report and TB clearance .Four (4) Staff files were reviewed. Last fire/earthquake drill was conducted in May of 2024. Infectious control plan was reviewed. Four (4) residents’ medications were reviewed. Medications are centrally stored and locked MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Tiffany Vander.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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