San Dimas Adventist Home Care

Type of visit: Required - 1 Year

LPA Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Gonzalez explained the purpose of the visit. The facility is located on a main street in the city of San Dimas and is licensed to serve the elderly 60 and above, fire clearance for six (6) non- ambulatory, facility main retain one (1) hospice resident and has a dementia program. The facility is a single story home consisting of a kitchen, dining area, living room, four (4) resident bedrooms and two (2) bathrooms, laundry room, a front yard and a backyard. 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, secured in the locked laundry room. LPA observed carbon monoxide detector in the hallway, was tested and is operable. Smoke detectors observed in the hallway and resident bedrooms, were tested and are operable. LPA inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA observed grab bars near toilets and inside showers. LPA observed no-slip flooring in showers. Showers were observed to be wheelchair accessible. continued on LIC 809C Food Service: LPA observed sufficient supply of nonperishables for one (1) week and perishable foods for a minimum of two (2) 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 Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed facility land line was operable. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Fire drills are conducted monthly, last drill 10/01/25. LPA observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs: No large bodies of water were observed. LPA observed signs posted indicating “No smoking - Oxygen in Use.” LPA observed an oxygen tank in resident room secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Health Related Services/Incidental Medical Services: The medications are centrally stored, secured in ta kitchen cabinet inaccessible to residents in care. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Jasaiel De Leon expires 04/03/2026. 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 observed required annual training, CPR and First Aid for two (2) personnel records reviewed. LPA observed TB testing results, Health screening, fingerprint clearance and job application for personnel records reviewed. Resident Records/Incident Reports: LPA reviewed files for four (4) residents in care. Resident files are maintained at the facility and contain the required documents. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview held and a copy of this report was provided to Administrator Jasaiel De Leon.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Ramirez explained the purpose of the visit. The facility is located on a main 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 four (4) resident rooms. All resident bedrooms 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 showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed sufficient supply of nonperishables 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 board games and activities for residents. 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. No proof of documented fire drill was observed during records review. LPA Ramirez will issue deficiency based on this record review. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. 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. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory device in resident bedroom#1 was in disrepair. LPA Ramirez will issue Type B deficiency based on this observation. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms 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 Jasaiel De Leon expires 04/03/2025. 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 two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) 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 six (6) non-ambulatory. This facility may retain no more than one (1) hospice resident. Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment were observed. LPA Ramirez did not observe Resident Rights form signed for R1, R2, and R3. R1 was missing complete Identification and Emergency form. LPA Ramirez will issue Type B deficiency. Four (4) deficiencies were observed today. A copy of this report, 809-D and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 11, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with DSP David Santiago and Administrator Jasiel Deleon showed up a short time later and assisted with the inspection today. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for Six (6) non- ambulatory residents. Currently there are 6 residents at the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control. The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies bit does not an Infection Control Plan. 2. Physical Plant and Environmental. The facility is a single story house and located around the residential neighborhood area. The facility includes living room, dining area, kitchen, four clients bedrooms, two bathrooms, Laundry area and an detached garage. LPA inspected the carbon monoxide detector and is working probably. The smoke detectors are in each room and common area, and they are working well. LPA tested the hot water temperature in two bathrooms and kitchen, and they were tested between 112.8 -114.9 degrees F. which is within the Title 22 regulation. All the sharp knives and utensils are locked in the kitchen cabinet. All the cleaning supplies and chemicals are locked in the laundry room. The facility has sufficient personal hygiene products for clients to use. All clients rooms are not completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway is safe and clear of obstructions. There is a broken wooden gate, ramp that needs repair or replacement and debris on one side of home that needs to be addressed. 3. Operational Requirements. The facility maintained a fire clearance approved by the fire department which 4 may be non-ambulatory. Currently All the clients in the facility are non-ambulatory. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire/disaster drill was conducted on 10/04/23. (Continue on 809C) 4. Staffing: The facility has sufficient staffing, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Jasaiel Deleon certificate will be expired on 04/03/2025. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours were posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. 10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed 2 residents' medication files and all medications are administered according to Doctor’s orders. 11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Facility needs to update emergency disaster plan. 12. Residents with Special Health Needs: No residents have prohibited health conditions. Deficiencies observed during today’s visit. See (809D) An exit interview was held. A copy of this report, 809D, technical advisory notes, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 6, 2023