197604374-3-13-2024-11-AS-SDAY-D3BSMH-20240313135958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604374
Report Date: 03/13/2024
Date Signed: 03/13/2024 02:00:10 PM

Document Has Been Signed on 03/13/2024 02:00 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	AYRES RESIDENTIAL CARE HOME		FACILITY NUMBER:	197604374
ADMINISTRATOR:	ANTANINA REMEIKIENE		FACILITY TYPE:	740
ADDRESS:	10862 WELLWORTH AVE		TELEPHONE:	3104756484
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90024
CAPACITY:	6	CENSUS: 5	DATE:	03/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Arielle Lewis		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the required inspection. LPA met with Arielle Lewis , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents of which one may be bedridden. The facility has an approved hospice waiver for 5 residents. There are residents diagnosed with dementia, Three (3) residents are receiving home health and one (1) resident is receiving hospice care services. The facility does not handle any of the residents’ money.

This home is a single story home consisting of: (6) resident bedrooms, (6) Full bathroom, break room, office, living room, kitchen, dining room, laundry room , salon area and an outdoor shaded area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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 03/13/2024 02:00 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197604374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Resident # 2, Resident 4 and resident #5 did not have current yearly appraisals on file for review as required for dementia residents.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Corrected at time of visit

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(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. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Resident # 2, Resident 4 and resident #5 did not have current yearly appraisals on file for review as required for dementia residents.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Corrected at time of visit

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/13/2024 02:00 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197604374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Resident # 2, Resident 4 and resident #5 did not have current yearly appraisals on file for review as required for dementia residents.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Appraisals were sent to facility while LPA was present: Corrected at time of visit

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AYRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 197604374
	VISIT DATE: 03/13/2024

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Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies:

-On 3/13/24 11:30 am LPA reviewed Resident #2, Resident #4 and R#5 records. LPA observed the records are incomplete. The above residents file did not contain Current medical assessment nor current appraisals.

During todays visit All documents were received and placed in residents file.

An exit interview was conducted and a copy of Report and Appeal Rights provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle Day	TELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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