Durando Home

Type of visit: Required - 1 Year

On 08/18/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The House Manager, Nancy Magallanes arrived shortly after to assist with today’s visit. LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 12:30 PM and the following was noted: The facility is a single-story building with seven (7) bedrooms and three (3) bathrooms currently occupying three (3) residents. There is a designated staff room, staff office and storage room. The facility has an approved fire clearance for four (4) ambulatory residents. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level III Residential Care for the Elderly. Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. LPA observed a fire extinguisher to be located near the kitchen and dated 01/30/2025. LPA observed required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights to be located throughout the common areas. A working telephone was observed. Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked kitchen cabinet. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C) Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed stored within storage closets located in the hallway’s passageway. Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations at 106.7 °F. Staff Room: LPA observed the staff room to be kept locked and inaccessible to residents. Laundry Room: The laundry room was observed to be located near the staff room and kept locked. LPA observed cleaning solutions and toxins stored within the laundry room and inaccessible to residents. The laundry appliances were observed to be working and in proper condition. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water located at the facility. Medications: The medications and First-aid kit were observed stored in a locked cabinet located in the kitchen. Smoke detectors and carbon monoxide observed to be working properly and were tested. The last Fire Drill was conducted on 8/16/2025. Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be missing reappraisals for all three residents. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be missing one (1) staff member (S1) Cardiopulmonary Resuscitation (CPR)/ First Aid certificate. S1’s CPR/First-Aid certificate was observed to be expired with a date of 7/30/2025. S1 was the only caregiver on duty upon LPA's arrival. There were no other immediate health and safety hazards observed during the day of inspection. Citations issued please see 809-D. Exit interview conducted, Appeals Rights given, and a copy of this report was provided to the House Manager.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lorena Casillas met with Administrator James Durando for an unannounced one (1) year Required visit for this facility. LPA arrived at 9:30 am and was greeted by caregiver and Administrator. One (1) resident observed in the living room watching TV, one (1) resident in the community, and two (2) residents at day program. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted. A tour of the physical plant was conducted with the Administrator at 09:50 am. The facility has seven (7) bedrooms and three (3) bathrooms. Four (4) rooms are currently used by residents, one (1) bedroom is used as an office, one (1) room as a storage room, and one (1) room is used as a staff bedroom. LPA observed that staff bedroom was locked, and residents do not have access to it. Infection control: LPA reviewed facility mitigation plan (approved on 04/22/2021) to make sure licensee was following current infection control recommendations. Living and Dining: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. No obstructions or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen, and it was last serviced on 12/18/2023. The laundry area was located in a backroom and all chemicals observed to be locked and inaccessible to residents. The washing machine is currently being repaired and a replacement washing machine is being used instead, Administrator states that they are waiting on parts for the broken down washing machine. The replacement washing machine is located in the facility and is functioning properly. Smoke and carbon monoxide detectors were located throughout the facility, and at 10:15 am they were tested and observed to be operational. Continued on LIC-809-C. Kitchen: During LPA’s visit, a repairman was in the facility currently repairing the fridge. A replacement fridge is located in the spare bedroom, it is working properly and is stocked with ample amounts of food. LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible. The medications are stored in a locked cabinet in the kitchen. LPA observed a first aid kit stored in a locked cabinet in the kitchen. Bathrooms: At 10:10 am LPA observed all bathrooms are clean and in good repair. The hot water temperature measured 115.7°F. LPA observed appropriate grab bars and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Bedrooms: There are four (4) bedrooms designated for residents’ use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Physical environment: At 10:30 am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. Administrative: Liability/Bond Insurance, LIC500 and client roster will be emailed to LPA. Annual fees are current. Resident/Staff Files: LPA conducted a file review of resident and staff records at 12:00 pm. Medications: At 1:00 pm LPA and Administrator reviewed medication and medication records for proper documentation. Staff Interviews: At 01:30 pm LPA interviewed staff. Client Interviews: At 02:00 LPA interviewed client. There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Facility staff did not meet a resident's medical needs. Facility staff failed to meet the needs of the resident.

On 05/15/2024 Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Staff #1 (S1), who granted access to the facility. S1 contacted the Administrator and LPA explained the reason for the visit. Administrator James Durando arrived shortly after. On 01/18/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations mentioned above. On 01/24/2024, LPA Casillas initiated the complaint visit. LPA conducted tour of the facility and obtained copies of pertinent information which includes, but not limited to Physician’s Reports, Hospital records, Appraisal Needs and Services Plan/IPP. LPA also conducted an interview with the Administrator, one (1) staff and one (1) out of four (4) residents who were able to communicate. Continued on LIC9099-C Substantiated Allegation #1 Facility staff did not meet a resident's medical needs. Regarding the allegation above, it was alleged that Resident #1 (R1) needs were not met by facility staff. Resident #1 (R1) was not reappraised at the hospital by facility staff, this caused hospital staff to release R1 back to facility. LPA reviewed hospital release paperwork dated 01/13/2024 where there is an indication that R1 needs medical equipment that LPA did not observe at the facility. Furthermore, hospital documents reflect that Physical Therapy is needed for R1, but Administrator was not able to produce any documentation to support that this need was met. Therefore, based on record reviews, interviews, and LPA observations this allegation is deemed Substantiated. Allegation #2 Facility staff failed to meet the needs of the residents. Regarding the allegations above it was alleged that Resident #1 (R1) was sent to the hospital alone and unsupervised by facility staff. Based on record review it is determined by a Physicians Report dated 01/25/2024 that R1 is not able to leave the facility on their own and requires supervision. During interviews with the Administrator and S1 it was determined that R1 was sent to the hospital on numerous occasions unsupervised by any facility staff. Therefore, based on interviews and record reviews this allegation is deemed Substantiated. Please see 9099-D. Citation issued. Appeals rights discussed and provided. Exit interview conducted. Copy of this report given to Administrator.the state’s words, verbatim · CDSS document, May 15, 2024 · control 31-AS-20240118100349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 22, 2024

87411 (a) Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews the Administrator failed to accompany or have staff accompany R1 to the hospital leaving R1 by themselves. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: POC Administrator agrees to have designated staff to accompany residents to all medical appointments or any appointments that require the resident to leave the facility. A new LIC500 will be submitted to LPA by POC due date via email to reflect additional necessary staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: May 22, 2024

87463 (c) Reappraisals (c) The licensee shall arrange a meeting with the resident…when there is a significant change in the residents’ condition...whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidence by: Based on interviews and record reviews the Administrator failed to meet with R1 at the hospital for a reappraisal. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: POC Administrator agrees to submit a new reappraisal for all residents in care via email, to LPA, by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 22, 2024

87465 (a)(1) Incidental Medical and Dental Care (a)A plan for incidental medical...care shall be developed by each facility. (1)The licensee shall arrange...medical and...appropriate to the conditions and needs of residents. This requirement is not met as evidence by: Based on interviews, record reviews and observations the Administrator failed to follow hospital release instructions for R1 based on hospital discharge paperwork. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: POC Administrator agrees to provide in-service training for all staff regarding preparing a plan of care for residents when there is a change in care. Training log will be provided to LPA via email by POC due date.

Allegation investigated: Facility staff did not follow reporting requirements.

On 01/24/24 at 9:30 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with Administrator James Durando and explained the reason for the visit. LPA Casillas was greeted by staff #1 (S1) and was granted entry. One (1) resident was observed to be in the living room watching TV, another resident was outside smoking a cigarette, a third (3rd) resident was in their room, the fourth (4th) resident was attending day program. At 9:45 AM LPA Casillas conducted a physical plant tour with S1. During the investigation, interviews and record reviews were made. LPA requested resident roster, LIC 500 and liability insurance. LPA requested copies of pertinent information relevant to the investigation including but not limited to, resident records, copy of hospital records and any other information pertaining to resident care. Continued on LIC9099-C Substantiated Allegation: Facility staff did not follow reporting requirements. It was alleged that facility staff did not follow reporting requirements. During resident records review it was determined that Special Incident Reports (SIR’s) were not submitted to Community Care Licensing (CCL) for Durando Home Inc. There is record of an SIR being reported on 11/14/2023. In the SIR dated 11/14/2023, it states that “R1 has not shown any progress since her last ER visit on 10-08-2023. Her primary care physician requested we arrange transportation to Hollywood Community Hospital for further assessment and tests.” During investigation LPA observed that there is no record of an SIR being submitted on 10/08/2023 for Durando Home Inc. The SIR’s that were submitted were under Durando Home III, subsequently there is no record nor are there any other SIR’s being submitted from this facility, Durando Home Inc. Due to Durando Home Inc not properly identifying the correct facility that SIR’s should have been sent to, this allegation “Facility staff did not follow reporting requirements.” is SUBSTANTIATED. Citation Issued. Appeal rights discussed and provided. Exit Interview conducted. Allegation: Facility staff did not ensure that a resident(s) has an appropriate bed. It was alleged that the facility did not ensure that residents had an appropriate bed “bed is not appropriate. it is a thin, metal fold-away bed.” Based on facility inspection and interviews it was determined that resident beds are appropriate. During the facility inspection LPA Casillas found that resident beds are beds with an appropriate mattress with springs and bedding, therefore this allegation “Facility staff did not ensure that residents have an appropriate bed.” is UNSUBSTANTIATED. Exit Interview conducted. Copy of this report provided to Administrator.the state’s words, verbatim · CDSS document, Jan 24, 2024 · control 31-AS-20240118100349

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 2, 2024

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing...within seven days of the occurrence ...This report shall include… disposition of the case. This requirement is not met as evidenced by: Based on interviews with staff, witnesses and file reviews, the Administrator failed to report incidents that happened to resident in Durando Home Inc. to CCL within 7 days which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: All staff will take state approved vendorised training on Reporting Requirements. Administrator will submit training material and staff sign in sheet to LPA via email by 02/02/2024.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 01/24/2024 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint 31-AS-20240118100349. This Case Management is not related to the original complaint visit. During the facility tour LPA observed that there was not enough perishable food for two (2) days. During LPA’s tour, LPA observed there was not a two-day supply of non-perishable food items. LPA observed that there was no food available for the lunch meal. LPA was told by staff (S1) that food was to be purchased as of Monday 01/22/24 but nothing had been delivered or brought to the facility. LPA Casillas explained the Administrator will need to immediately purchase a two-day supply of perishable food. LPA explained the due date was 01/24/2024. LPA also advised Administrator that a weekly menu will need to be sent to LPA Casillas via email for the next six weeks. During course of visit, Administrator purchased sufficient perishable food for two-days for all residents in care. Citation Issued. Appeal rights discussed and provided. Exit Interview conducted.the state’s words, verbatim · CDSS document, Jan 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Jan 24, 2024

87555General Food Service Requirements(b)The following food service requirements shall apply: (26)Supplies ... and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on LPA’s view of the food supply, the licensee did not comply with the section cited above in not providing a two day supply of perishable foods this poses a Health, Safety, and Personal risk to residents in care.the state’s words, verbatim · CDSS document, Jan 24, 2024

Plan of correction: Administrator purchased perishable food that was delivered to the facility on day of visit. Administrator will provide a weekly menu to LPA via email for the next six weeks.