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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606448
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:49:15 PM


Document Has Been Signed on 02/15/2024 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:RISE N' SHINE VILLA IIFACILITY NUMBER:
197606448
ADMINISTRATOR:ERLINDA L HATMALFACILITY TYPE:
740
ADDRESS:5203 JOSIE AVENUETELEPHONE:
(562) 461-8836
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY:6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver Cheryl LacambraTIME COMPLETED:
04:02 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Sanjay Vaid and Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPAs met with Caregiver Cheryl Lacambra and explained the reason for the visit. The Administrator Erlinda Hatmal arrived shortly after. The facility is licensed to serve six non-ambulatory residents ages 60 and above and may retain one hospice resident. Facility is not operating within the scope of its license due to currently having 1 bedridden resident and 2 hospice residents.

A tour of the single-story facility included: kitchen, dining area, living room, laundry room, 4 resident rooms, 1 caregiver room, 1 resident bathroom, 1 staff bathroom, front yard, and backyard. LPAs and Cheryl toured the facility, and the following was observed: The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Auditory devices were seen on exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the residents’ bathroom and measured at 117.4 degrees F which is within the required 105 - 120 degrees F. The bathroom is clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in the caregiver’s room. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is a carbon monoxide in the hallway, and it is properly operating. There are 2 fire extinguishers located in the kitchen and laundry room which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are kept locked under the kitchen sink and are inaccessible to residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Cleaning supplies and toxins are locked in a cabinet in the laundry room and are inaccessible to residents. First Aid kit was fully stocked with current manual and it is kept locked in the residents’ medication cabinet in the kitchen. Residents medications are centrally stored in a locked cabinet in the kitchen. Residents and staff files are centrally stored in a locked cabinet in the dining area. LPAs reviewed 5 residents’ medication and observed that medication properly documented and given as prescribed. LPAs reviewed 5 client files and 4 staff files. LPAs interviewed 1 staff and 2 residents. LPAs observed bed rails on R1, R2, and R3, but there was no doctor's orders for those bed rails in their files.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 02/15/2024 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: RISE N' SHINE VILLA II

FACILITY NUMBER: 197606448

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care. R2 physician's report states that R2 is bedridden. Facility is not licensed for bedridden residents.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee is to submit an LIC 200 and facility sketch which clarifies the room with the bedridden resident to CCLD by 02/16/2024 OR will have R2 reassess to determine if R2 is non-ambulatory and submit new physician report to CCLD by 02/22/2024.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2024 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: RISE N' SHINE VILLA II

FACILITY NUMBER: 197606448

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) 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:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care. R1, R2 and R3 had bed rails attached to their beds, but there was no doctor's orders for the bed rails in their files.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, the Licensee will obtain doctor's orders for the bed rails and submit copies to CCLD by 02/22/2024.
Type B
Section Cited
CCR
87632(a)(1)
(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following: (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R2 and R3 are in hospice and facility is approved for only 1 hospice resident.
POC Due Date: 02/22/2024
Plan of Correction
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Licensee is to comply with Title 22 Section 87632 at all times. Additionally, the Licensee will submit a new hospice waiver request to increase the hospice capacity to CCLD by 02/22/2024.
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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Sanjay VaidTELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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