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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606626
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:30:59 PM


Document Has Been Signed on 05/22/2024 04:30 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ARAYATA ELDERLY CAREFACILITY NUMBER:
197606626
ADMINISTRATOR:NATIVIDAD ARAYATAFACILITY TYPE:
740
ADDRESS:44849 LOTUS LANETELEPHONE:
(661) 948-4985
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
05/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:44 PM
MET WITH:ARAYATA NATIVIDADTIME COMPLETED:
04:30 PM
NARRATIVE
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On 05/22/2024, Licensing Program Analysts (LPAs) Evelin Rios and Lorena Casillas conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240515150750. LPA met with Staff #1 (S1) who granted access to the facility. The Administrator met LPAs at 2:30 p.m and LPAs explained the reason for the visit.

During the visit, LPAs were informed that R1 had a difficulty breathing on 05/13/2024. 9-1-1 was called and R1 was taken to the hospital. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident report was submitted to the Regional Office (RO). LPA informed the Administrator to submit an incident report that occurred for the 05/13/2024 incident involving R1.

During the physical plant tour LPAs observed the following:
  • LPA's observed 3 cameras in common areas and one (1) camera in resident#3's (R3's) bedroom. According to Administrator they believe they included cameras in their plan of operation. Administrator could not provide the documentation at time of visit. According to administrator R3's family gave consent to have a camera in her room. According to administrator there is no sound and camera is live streaming only.
  • At 2:23 p.m. LPA Casillas observed a brick outside of the French doors leading to the backyard in bedroom labeled #3 meant to prevent the door from opening. According to Administrator the door does not stay closed and it has been like that for two weeks. According to staff it is used to prevent R2 from wondering.

Deficiencies are cited refer to 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
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 2


Document Has Been Signed on 05/22/2024 04:30 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ARAYATA ELDERLY CARE
FACILITY NUMBER: 197606626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
87307(d)(6)

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87307(d) The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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Administrator removed brick on todays visit. Administrator will submit a receipt or invoice to LPA by POC due date 05/31/2024.
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Based on LPA's observation and interviews Administrator confirmed placing a brick on the outside of the French doors labeled a fire exit, which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
05/28/2024
Section Cited
CCR87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...t within seven days of the occurrence ... This requirement is not met as evidenced by:
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Administrator will complete the incident report involving R1 to LPA by POC due date 05/28/2024.
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Based on LPA's interviews and record review Administrator confirmed an incident report involving R1 was not sent to CCL in a timely manner, which posed potential health, safety and personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2