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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197605806
Report Date:
03/16/2022
Date Signed:
03/16/2022 01:13:03 PM
Document Has Been Signed on
03/16/2022 01:13 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
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LAS CASITAS ASSISTED LIVING
FACILITY NUMBER:
197605806
ADMINISTRATOR:
NATALIE GONZALEZ
FACILITY TYPE:
740
ADDRESS:
1633-1645 N. HOLLYWOOD WAY
TELEPHONE:
(818) 238-9951
CITY:
BURBANK
STATE:
CA
ZIP CODE:
91505
CAPACITY:
17
CENSUS:
13
DATE:
03/16/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:20 AM
MET WITH:
Patricia Garcia, Manager
TIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Manager Patricia Garcia and explained the purpose of the visit. The facility is licensed for 17 non-ambulatory adults 60 and over. he facility has a hospice waiver for 2 residents. The facility is composed of 6 single story detached "Casitas" rooms, dining room/kitchen area, garages [3 converted into office space], medication room, and a center courtyard area. Administrator certificate expires 6/26/2022.
The following were observed/inspected:
The main entrance was locked. A wire was observed on the very top of the metal gate that prevents anyone inside the property from exiting in case of an emergency. Rear gate had a lock on right door.
COVID-19 screening, sign-in sheet, and temperature check was not conducted by staff upon entry, or to other visitor's observed.
COVID-19 Infection Control Practices and signs were observed in resident rooms, common areas, and throughout the facility.
The interior and exterior physical plant was inspected. Six (6) rooms were inspected. A signal system was observed to be operational. Breakfast was served at 10:00 AM. Lunch service was at 1:00 PM.
Resident rooms are designated as a COVID-19 isolation rooms if needed.
All staff were observed wearing mask. Residents in care were not observed wearing masks due to health issues.
Centrally stored resident medication records were reviewed. MAR records did not match MD orders.
Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
A posted Emergency Disaster Plan was observed.
Facility has sufficient supply of Personal Protective Equipment (PPEs).
Emergency Disaster drill records were not found. Disinfectants/cleaning solutions were observed in Dementia residents rooms.
***Deficiencies were cited. See LIC 809D.
Exit interview was conducted with Manager Patricia Garcia. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME:
Lisa Hicks
TELEPHONE:
(323) 981-3972
LICENSING EVALUATOR NAME:
Noemi Galarza
TELEPHONE:
(323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE:
03/16/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/16/2022
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
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Document Has Been Signed on
03/16/2022 01:13 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
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LAS CASITAS ASSISTED LIVING
FACILITY NUMBER:
197605806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/16/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observaton, the licensee did not comply with the section cited above in that LPA was not screened upon entry, which poses an immediate health, safety or personal rights risk to persons in care. COVID-19 screening protocols i.e. visitor sign-in binder, thermometer, and screening questions were not observed to be in place. Home health staff were also present during today's visit, and were not screened.
POC Due Date:
03/17/2022
Plan of Correction
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Administrator shall put in place COVID-19 infection control visitor screening practices. Submit in writing how this was corrected, and include a picture of the screening area.
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that during the physical plant tour of resident rooms, dementia residents (R1-R2's) room had a Febreze deodorizer and Clorox cleaning supplies inside room 1641, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/17/2022
Plan of Correction
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Administrator shall conduct staff training regarding regulation 87705, check all resident rooms for potential hazards, and submit proof of correction by POC due date.
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:
Lisa Hicks
TELEPHONE:
(323) 981-3972
LICENSING EVALUATOR NAME:
Noemi Galarza
TELEPHONE:
(323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE:
03/16/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/16/2022
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
03/16/2022 01:13 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
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LAS CASITAS ASSISTED LIVING
FACILITY NUMBER:
197605806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/16/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the main entrance gate is locked, and had a metal wire on the top of the gate preventing anyone inside the premises from exiting. In addition, the rear gate had a lock that prevents the right side door from opening. Locking mechanisms that require a key and/or inaccessible to residents for exit are against fire safety code which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/17/2022
Plan of Correction
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Administrator shall remove all locks that require key on exit doors, and wire placed by staff in the front entrance door. Submit picture proof, staff training log, and a written statement of what was done to correct it.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Lisa Hicks
TELEPHONE:
(323) 981-3972
LICENSING EVALUATOR NAME:
Noemi Galarza
TELEPHONE:
(323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE:
03/16/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/16/2022
LIC809
(FAS) - (06/04)
Page:
3
of
4
Document Has Been Signed on
03/16/2022 01:13 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
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LAS CASITAS ASSISTED LIVING
FACILITY NUMBER:
197605806
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/16/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that LPA requested to see the Plan of Operation to check meal/dining services, but staff was not able to find the Plan of Operation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2022
Plan of Correction
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Administrator shall submit a copy of the plan of operation, and ensure it is in the facility at all times.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that staff was not able to find record of the last facility emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2022
Plan of Correction
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Administrator shall conduct quarterly emergency drills. Submit proof of emergency drill by POC due date.
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:
Lisa Hicks
TELEPHONE:
(323) 981-3972
LICENSING EVALUATOR NAME:
Noemi Galarza
TELEPHONE:
(323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE:
03/16/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/16/2022
LIC809
(FAS) - (06/04)
Page:
4
of
4