La Verne Manor

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Alberto Lopez and Gabriela Castro conducted an unannounced Annual Required Visit. LPA met with John Michael Tanada and explained the purpose of the visit. This facility is licensed to serve 50 Ambulatory and 30 Non-Ambulatory residents (age 60 and above). Resident rooms #1 through #19, Room #24, Room #30, and Room #38 are cleared for non-Ambulatory residents only. Facility is approved for 8 hospice residents. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility does have an Infection Control Plan in place. Operational Requirements: Facility is adhering to the operational requirements. Physical Plant & Environment Safety: LPA toured facility grounds. Carbon Monoxide detectors were tested and operable. Fire extinguishers are located throughout the building and serviced. Signal system (alert/notification goes to the nurses station). Hot water temperature measured between 121. 5 – 124.0 which is not within regulations of 105.0 – 120.0 degrees. Bathrooms have non-skid surfaces and grab bars. Staffing: Facility is adhering to staffing requirements. **continued LIC 809C** (continued from 809) Personnel Records-Training: Staff files are maintained at the facility. LPAs reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting and Resident Rights. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: Activity schedule is posted. 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. Posted menu observed near the dining room. 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 clean and stored properly. Dining areas have adequate seating. Resident Records-Incident Reports: LPAs reviewed Resident files for Resident #1 (R-1) through Resident #4(R-4). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Appraisal Information, Appraisal/Needs and Services Plan, Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness plan in place but needs updating. Residents with Special Health Needs: Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. No resident currently on Hospice. Health Related Services/Incidental Medical Services: The medications are stored and locked inside the medication room. Medications are administered as prescribed. Medication Administration is documented in a Medication Administration Record (MAR) log. One PRN was missing label. Deficiencies cited, technical Violations provided. Exit interview conducted, copy of appeal rights and a copy of this report were provided to John Michael Tanada (Administrator).the state’s words, verbatim · CDSS document, Jan 29, 2026

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 2/3/2025 and was greeted by Administrator Michael Tanada. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms inspected contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Facility has video surveillance inside common areas. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed an activities schedule for the month of February 2025 posted. The facility does not have a full-time staff member, responsible to organize, conduct and evaluate planned activities. LPA Ramirez will issue a Type B deficiency based on this observation. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 1/3/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for John Michael Tanada expires 9/22/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for fifty (50) ambulatory and thirty (30) non-ambulatories. Rooms #1, thru #19, #24, #30 and #38 are cleared for non-ambulatory residents. This facility may retain no more than eight (8) hospice residents. There were zero (0) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) deficiency was observed and cited during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 9102, and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Feb 3, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Licensee is not addressing leaking ceiling

***This report supersedes report dated 02/02/2024, it was done to correct some information and nothing else has changed and the findings remain the same**** Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the above allegation. LPA met with Administrator, Michael Tanada and explained the reason for the visit. Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the above allegation. LPA met with Administrator, Michael Tanada and explained the reason for the visit. LPA interviewed 4 Staff S#1-S#4 and 5 residents R#1-R#5 and reviewed and obtained residents and staff rosters, food menu, and documentation indicating residents who are provided second servings during breakfast, lunch or dinner. (Continued on 9099C) Substantiated The investigation revealed: LPA took tour of entire facility with Administrator and noticed room #2 #8 and #21 had water damage on the ceiling. One room had a bucket to collect water and it had about 2 inches of water in the bucket. The floor was also covered with wet bed pads to absorb the leakage. LPA interviewed 4 staff and 3 of 4 staff denied the allegation, and one staff stated that there was a small leak in the kitchen, but has been fixed. LPA did not observe any leaks in the kitchen, but there was some damage to the ceiling, and Administrator stated maintenance man and himself are repairing it. LPA interviewed 5 residents and 5/5 could not collaborate with the allegations and all 5 stated that their rooms do not have leaks. LPA did not observe any of the rooms that were occupied to have leaks. Based on LPA observations during tour of facility with Administrator, the preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 the deficiencies issued were documented on LIC 9099D.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 28-AS-20240130125333

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Annual Required Visit. LPA met with John Michael Tanada and explained the purpose of the visit. This facility is licensed to serve 50 Ambulatory and 30 Non-Ambulatory residents (age 60 and above). Resident rooms #1 thru #19, Room #24, Room #30, and Room #38 are cleared for non-Ambulatory residents only. Facility is approved for 8 hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility does has an Infection Control Plan in place. Operational Requirements: Facility is adhering to the operational requirements. Physical Plant & Environment Safety: LPA toured facility grounds. Carbon Monoxide detectors were tested and operable. Fire extinguishers are located throughout the building (last serviced on 10/05/23). Signal system (alert/notification goes to the nurses station) tested and operable in rooms 3,16,29 and 38. Hot water temperature measured within regulations. The hot water supply measured at the following temperatures: Room #3 (109.0*), Room #13 (108.0*), Room #16 (106.0*), Room #29 (113.1*) and Room 38 (107.0*). Bathrooms had non-skid surfaces and grab bars. Staffing: Facility is adhering to staffing requirements. **Refer to LIC 809C for the continuation of this report.** Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: Activity schedule is posted. 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. Posted menu observed near the dining room. 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. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Appraisal Information, Appraisal/Needs and Services Plan, Resident Rights were observed. Disaster Preparedness: The facility has a Disaster Preparedness plan in place. Residents with Special Health Needs: Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there is (1) resident utilizing oxygen equipment and there is (1) resident under hospice care. Health Related Services/Incidental Medical Services: The medications are stored and locked inside the medication room. Medications are administered as prescribed. Medication Administration is documented in a Medication Administration Record (MAR) log. Exit interview conducted, copy of appeal rights and a copy of this report was provided to John Michael Tanada (Administrator).the state’s words, verbatim · CDSS document, Feb 7, 2024

Allegation investigated: Licensee is not addressing leaking ceiling

Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the above allegation. LPA met with Administrator, Michael Tanada and explained the reason for the visit. LPA interviewed 4 Staff S#1-S#4 and 5 residents R#1-R#5 and reviewed and obtained residents and staff rosters, food menu and documentation indicating residents who are provided seconds during breakfast, lunch or dinner. The investigation revealed. LPA took tour of entire facility with Administrator and noticed room #2 #8 and #21 with water damage on the ceilings. One room had a bucket to collect water and it had about 2 inches of water in bucket. The floor was also covered with wet bed pads to absorb the leaking. LPA interviewed 4 staff and all 3 of 4 staff denied the allegation, One staff stated that there was a small leak in the kitchen but has been fixed. LPA did not observe any leaks in the kitchen but there was some damage to the ceiling and administrator stated maintenance man and himself are repairing it. (Continued on 9099C) Substantiated Based on observation, interviews, and records reviewed, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the administrator. LPA interviewed 5 residents and 5/5 could not collaborate the allegations and all 5 stated that their rooms do not have a leak. LPA did not observe any of the rooms that were occupied to have leaks. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22 the deficiencies issued were documented on LIC 9099D.the state’s words, verbatim · CDSS document, Feb 2, 2024 · control 28-AS-20240130125333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 2, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: LPA and Administrator observed rooms #2, #8 and #21 with severe water damage on the ceiling and a water bucket in one room to collect leaking water as well as wet bed pads spread out on the floor to absorbed the excess water which poses/posed a health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Administrator will repair the 3 rooms and send proof to LPA by POC date in form of photos, and invoices of the 3 rooms. Civil penalties for $1000 issued for repeat violation.