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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606449
Report Date: 05/13/2022
Date Signed: 05/13/2022 12:56:58 PM

Document Has Been Signed on 05/13/2022 12:56 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:D' ELDERS "R" USFACILITY NUMBER:
197606449
ADMINISTRATOR:REBECCA V. LIMFACILITY TYPE:
740
ADDRESS:21514 ALAMINOS DRIVETELEPHONE:
(661) 513-1336
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: 4DATE:
05/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Ruskie Ragasa, Co-AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management to the facility. LPA met with the co-administrator, Ruskie Ragasa and explained the reason for the visit.

This visit is based on the information received by Woodland Hills South Regional Office (WHSRO) from the Centralized Applications Bureau (CAB). Ragasa recently submitted an application for licensing which is currently under review. During the review, it was discovered that the co-licensee, Eddie M Sotiangco, died 04/23/2022 and the decedent's spouse, Rebecca Lim is the current administrator and co-licensee. The facility is currently operating under a corporation that is owned by the decedent Sotiangco and the surviving spouse Lim. Upon review it was discovered that the corporation has a standing of "Not Good" with the Franchise Tax Board (FTB) California with a Statement of Info Due Date 07/31/2021. LPA contacted Lim and inquired about the unpaid taxes and Lim responded, "I do not know the current status. My husband was the one who took care of all of the paperwork." LPA asked about the current lease agreement and Lim responded, "I do not know where those documents are. I will have to look for them. My husband was cremated yesterday, and I am still trying to figure things out." LPA asked Ragasa about control of the property and Ragasa replied, "I believe the property was sold in 2018 or 2019." Ragasa stated that he has a lease agreement with the current owner and that he submitted it along with the application.

During questioning and a plant inspection, LPA observed the following deficiencies;
Bedrooms #1 and #3 have half bed rails with no prescriptions and Bedroom #2 has a full bed rail with no prescription.

Administrator has not maintained or supervised the maintenance of financial and other records.

(cont. on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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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: D' ELDERS "R" US
FACILITY NUMBER: 197606449
VISIT DATE: 05/13/2022
NARRATIVE
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Administrator did not notify the residents of the intent to sell the business.

Administrator did not notify the Department by the next working day of the licensee’s death.

Based on observations during the visit, deficiencies were cited, and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and Appeal Rights were discussed and provided to the Administrator, whose signature on this form confirm receipt of these documents.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/13/2022 12:56 PM - It Cannot Be Edited


Created By: Abeye Duguma On 05/13/2022 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: D' ELDERS "R" US
FACILITY NUMBER: 197606449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2022
Section Cited
CCR
87608(a)(3)

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87608(a)(3) A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed.
This requirement is not met as evidenced by;
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The Administrator will contact the doctors. The correct prescription of the postural support specifying the need of usage will be obtained. Copies of the prescription must be submitted to CCL by POC due date.
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The licensee did not ensure to keep a prescription and usage of half bedrail. 2 out of 4 residents were using half bedrails as a postural support. No prescription signed by the doctor explaining need of usage exists. This poses an immediate health and safety risk to residents in care.
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Type A
05/14/2022
Section Cited
CCR87608(a)(B5)

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87608(a)(B5) Postural Supports. Bed rails that extend the entire length of the bed (full bed rails) are prohibited except for residents on hospice and their hospice care plan specifying the need of usage. This requirement is not met as evidenced by;
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Within 24 hours the Licensee will provide copies of the physician order for the postural support. POC Must be provided to CCL by POC due date.
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The licensee did not ensure to obtain a prescription for postural support. One resident residing at the facility is using a full bed rail. No prescriptions observed in facility records. This poses an immediate risk to the health and safety 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 Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 12:56 PM - It Cannot Be Edited


Created By: Abeye Duguma On 05/13/2022 at 12:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: D' ELDERS "R" US
FACILITY NUMBER: 197606449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
CCR
87405(d)

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Administrator-Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records.
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Licensee will provide a written statement explaining how they will ensure that, moving forward, the facility will maintain financial and other records.
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This requirement is not met as evidenced by:

Licensee/Administrator did not ensure to maintain required records. This poses a potential personal rights risk to residents in care.
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Type B
05/16/2022
Section Cited
CCR87111(b)

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87111 (b) Continuation of License Under Emergency Conditions. In the event of a licensee’s death, an adult who has control of the property….shall…(1) notify the Department by the next working day of the licensee’s death. This requirement is not met as evidenced by;
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Licensee will provide a written statement explaining how they will ensure that, moving forward, the facility will abide by the regulation.
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The Administrator/Licensee failed to notify the Department of the licensee’s death in a timely manner. This poses a potential personal rights 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 Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 12:56 PM - It Cannot Be Edited


Created By: Abeye Duguma On 05/13/2022 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: D' ELDERS "R" US
FACILITY NUMBER: 197606449

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2022
Section Cited
HSC
1524.1

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Sale of licensed community care facility resulting in the issuance of new license; conditions; exemptions….(2) the licensee shall, inform all residents….the licensee’s intent to sell the property or business. This requirement is not met as evidenced by;
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The Licensee/Administrator shall inform the residents, in writing, of their intent to sell and notify their responsible parties. The Licensee/Administrator will provide the Department with a copy of all distributed letters by the POC due date.
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The Administrator/Licensee did not notify the residents of the intent to sell in writing. This poses a potential personal rights 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 Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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