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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602038
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:52:34 PM


Document Has Been Signed on 07/20/2022 03:52 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:SARAH KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
07/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Roderick Kirk, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Case Management visit in conjunction with complaint control number 31-AS-20220223161449. The purpose of this Case Management visit is to issue citations for deficiencies observed during the course of the complaint investigation that is not directly related to the complaint. LPA met with Roderick Kirk, Administrator.

During the investigation, LPA Valenzuela and IB Investigator Dennis Douglas observed the following:

1) Untimely medical care. Paramedics were called to the facility 2 hours after R1 was found being unresponsive.

2) Resident did not receive diabetic care. Oral medication/Insulin was not administered.

3) Administrator lacking qualifications. Admitted to the facility a resident with prohibitive health conditions.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and cited during the visit. Exit interview conducted, a copy of the report, citations, and appeal rights were issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited

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87465(g)- Incidental Medical and Dental Care
The Licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health including, but not limited to, an apparent life-threatening medical crisis...
This requirement was not met as evidenced by:
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Based on record review, the licensee failed to call 911 immediately after being notified that a resident was being unresponsive.

This poses an immediate health and safety risk to residents in care.
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Type B
07/27/2022
Section Cited

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87628(b)(2) Diabetes
(b)...the licensee shall be responsible for the following:...(2) ensuring that sufficient amounts of medicines, testing equipment, syringes, needles, and other supplies are maintained and stored in the facility as specified in Section 87456(c).
This requirement was not met as evidenced by:
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Based on interviews and record review, the licensee did not ensure that a diabetic resident had their medications at the facility in order for a home health agency nurse to administer it to them.

This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/20/2022 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: FLOWERS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197602038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited

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87405(d)(1)(2) Administrator Qualifications and Duties- The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of the ability to conform to the applicable laws, rules, and regulations...
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This requirement was not met as evidenced by:

Based on interview and record review, the administrator admitted a resident to the facility with a prohibitive health condtion
This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3