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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603552
Report Date: 04/17/2025
Date Signed: 04/17/2025 10:52:06 AM

Document Has Been Signed on 04/17/2025 10:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ST. CECILIA'S SENIOR HOME IVFACILITY NUMBER:
198603552
ADMINISTRATOR/
DIRECTOR:		VANDER POORTEN, JOSIAHFACILITY TYPE:
740
ADDRESS:2033 E. PETUNIA ST.TELEPHONE:
(909) 802-9144
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
04/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Cholly Sason and Tiffany Vander PoortenTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an annual inspection visit. LPA met with Cholly Sason and discussed the purpose of today’s visit. Tiffany Vander Poorten (Administrator) arrived at approximately 9:05 A.M..

This home is a single-story home with a fire clearance for (6) non-ambulatory residents. This home also has an approved Dementia Care Plan and a Hospice Waiver approved for (6) residents. There are currently (2) residents receiving hospice care. There are (3) residents receiving Home Health Agency services. LPA obtained a copy of a current liability insurance coverage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control Policy in place and was observed to be posted.
Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. Fire smoke alarms and carbon monoxide detector (located in the hallway) observed. The fire extinguishers were observed and appeared to be full (one located near the kitchen/dining area and one located inside the laundry room). Last drill was conducted on 01/22/25. Bedrooms have the required furniture. Ample supply of food (perishable and non-perishable) was observed. Ample linen supplies were also observed. Bathrooms have non-skid surfaces and grab bars. Hot water temperature measured at 106.8* and 107.4 * in the hallway bathrooms and 106.5* in the bathroom inside bedroom # 4. ***Refer to LIC 809C for the continuation of this report***.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/17/2025
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Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for S-1 through S-5. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Resident Rights-Information: Resident rights are posted and are included in Resident files.

Planned Activities: Activity provides planned activities. This facility also provides internet access to the clients.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Resident file has the required documents. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment and Preplacement Appraisal Information, Resident Pre-Appraisal. Resident Rights were observed.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.

Health Related Services/Incidental Medical Services: The medications are stored and locked. Medications are administered as prescribed.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Tiffany Vander Poorten (Administrator).
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
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