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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602038
Report Date: 10/11/2023
Date Signed: 10/11/2023 02:35:29 PM


Document Has Been Signed on 10/11/2023 02:35 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:FLOWERS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197602038
ADMINISTRATOR:RODERICK KIRKFACILITY TYPE:
740
ADDRESS:2762 VISSCHER PLACETELEPHONE:
(626) 797-7996
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:6CENSUS: 5DATE:
10/11/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Roderick Kirk - AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management non-compliance visit at this facility to follow up on Non-Compliance Conference held at the Woodland Hills Adult and Senior Care Regional Office (WHASCRO) South on 04/11/23.

During this visit, LPA reviewed residents and staff record at 9:30 AM. During the review, LPA discovered that two (2) out of five (5) residents have physician's report (LIC 602) that has no signature and no TB test. One (1) out of five (5) residents has an admission agreement that is not signed both by the licensee and the resident. Two (2) staff files were also reviewed two (2) out of two (2) residents have no current first aid certificate on file.

Also during this visit, LPM Naira Margaryan record review revealed that the facility admitted Resident #1 (R1) with stage IV pressure injury in March 2023.

Physical plant tour conducted by LPM Margaryan at 10:30 AM also observed that R1 has half bed rail on own bed and did not find any physician's order for the bed rail on file.

Citation issued. Civil penalty assessed. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 10/11/2023 02:35 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
WOODLAND HILLS S.ASC, 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: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
87615(a)(1)

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Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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The administrator stated that he will talk to the family of R1 to move R1 to a higher level of care and will submit proof of moving on or before the POC date.
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This requirement is not met as evidenced by:

Based on record review R1 was admitted with stage 4 pressure injury in March and retained to this date, This poses an immediate health and safety risk to the residents in care.
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Type A
10/12/2023
Section Cited
CCR87608(a)(3)

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A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
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The administrator removed the 1/2 bed rails during the visit.

Cleared during visit.
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Based on observation the licensee failed to ensure that R1 has a written order for postural support placed on R1's bed. This poses an immediate health and safety risk to the 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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/11/2023 02:35 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
WOODLAND HILLS S.ASC, 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: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
87411(c)(1)

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Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
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The administrator and staff took the training today and was issued a current certificate.

Cleared during the visit.
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Based on revord review 2 out of two staff records reviewed did not have current first aid training certificate on file. This poses an immediate health and safety risk to the residents in care.
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Type B
10/20/2023
Section Cited
CCR87458(a)

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(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year ....

This requirement is not met as evidenced by:
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The administrator agreed to obtain the signature for the physician's report and get the TB test done and will submit a signed copy to CCL on or before the POC date.
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Based on record review, 2 out 5 residents had medical assessment on file without the physician's signature and no TB test was done. This poses a potential health and safety risk to the 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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/11/2023 02:35 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
WOODLAND HILLS S.ASC, 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: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
87405(d)(1)

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Knowledge of the requirements for providing care and supervision appropriate to the residents

This requirement is not met as evidenced by:
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The administrator agreed to attend additional training for residents care and supervision.
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Based on, interview, record review and observation, the administrator did not ensure to provide appropriate care to the residents in need of care. This poses an immediate health and safety risk to the residents in care.
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Type B
10/20/2023
Section Cited
CCR87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
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The administrator agreed to obtain the signature for the admission agreement and send a signed copy to CCL on or before the POC date.
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Based on record review, 1 out 5 residents has no signed admission agreement on file. This poses a potential personal rights risk to the 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: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4