198603552-5-4-2023-28-AS-ALOZ-CRHUNN-20230504154414

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603552
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:44:29 PM

Document Has Been Signed on 05/04/2023 03:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ST. CECILIA'S SENIOR HOME IV		FACILITY NUMBER:	198603552
ADMINISTRATOR:	VANDER POORTEN, JOSIAH		FACILITY TYPE:	740
ADDRESS:	2033 E. PETUNIA ST.		TELEPHONE:	(909) 802-9144
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY: 6		CENSUS: 6	DATE:	05/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:22 AM
MET WITH:	Tiffany Vander Poorten, Licensee		TIME COMPLETED:	03:51 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alberto Lopez conducted an annual required visit. LPA met with Licensee Tiffany Vander Poorten and explained the reason for the visit. Home has a fire clearance from the local Fire Department for a capacity of 6 non-ambulatory and hospice waiver for 6 LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection control plan at facility. Physical Plant & Environment Safety: . There are 4 client bedrooms, 2 are shared rooms. 3 bathrooms, 3 with showers, living room, activity room, dining room, kitchen, laundry room, detached garage used as storage. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway and was tested. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in measured 105.2- 109.2 degrees F which is within the required range of 105-120 degrees F. Operational Requirements The licensee provides care and supervision as required. Has fire clearance. Staffing: There appears to be sufficient staffing at the facility. The administrator’s certificate expires 04/02/2025 Staff employed are all over the age of 18. Planned Activities: Facility staff encourage residents to participate in activities and one resident was playing solitaire with family member during LPA visit. Continue on 809C

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ST. CECILIA'S SENIOR HOME IV	FACILITY NUMBER: 198603552
	VISIT DATE: 05/04/2023

NARRATIVE

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Resident Rights/Information: Resident rights are posted at facility and staff are familiar with resident rights.
Personnel Records-Training: Staff files are maintained at the facility. All staff have current CPR first aid training. Facility has documentation on file that verify CPR for 2 staff.
Client’s Records-Information: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, pre-admission assessment and other required documentation.
Food Service: There are sufficient food supplies of 2-day perishable and a week (7 days) of non-perishable items. The food is properly stored in the refrigerator to avoid cross contamination.
Health Related Services: Clients are assisted with medication administration and dental and medical appointments including arranging transportation.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA reviewed 6 client’s medication and medication is administered following physician’s orders.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last emergency drill 01/10/2023

During the visit today, LPA did not observed deficiencies at time of visit. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Licensee Tiffany Vander Poorten

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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