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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606693
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:48:49 PM

Document Has Been Signed on 07/22/2021 01:48 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" US IIFACILITY NUMBER:
197606693
ADMINISTRATOR:JOSEPHINE MARQUEZFACILITY TYPE:
740
ADDRESS:28001 CERO DRIVETELEPHONE:
(661) 263-8080
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: 3DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Administrator Josephine MarquezTIME COMPLETED:
02:00 PM
NARRATIVE
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At 9:30am Licensing Program Analysts (LPAs) Angela Panushkina, Melissa Ruiz and Licensing Program Manager (LPM), Nichelle Gylliard conducted an unannounced annual inspection at the above facility. Team met with the caregiver Carmelita Posadas and Angelita Vicente who granted access to home. This is a 5 bedroom, 2 bathroom, single story family residence that includes a living room, dining area, kitchen, laundry room and attached garage. LPA toured the entire facility with the Administrator who arrived at 10:10 am, and observed the following:

Infection control: LPA Panushkina reviewed facility mitigation plan (approved on 04/10/21) to make sure licensee was following current infection control recommendations. Upon arrival the team was not screened by the caregivers and were not asked any infection control questions. The screening log was last filled out by a visitor in March of 2021. The team had to prompt and guide staff through the screening process.

Food Inspection: At 10:45 the team conducted a food inspection tour an found the following: The facility doesn't have sufficient supply of 2 days perishable foods and one week of non-perishable foods. Team observed food cabinets to have pad locks. Food is locked at night to prevent a resident from having access. This is a personal rights violation. The kitchen knives were observed to be accessible to residents in care.

There is one carbon monoxide detector in the kitchen area. Smoke detectors were checked and are hardwired throughout the facility. Smoke detectors and carbon monoxide are observed to be operational.

Bedrooms: There are four bedrooms designated for residents' use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms are in poor repair at the front door and in room #3. The facility has Dementia residents in care and this poses a potential health and safety risk.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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 II
FACILITY NUMBER: 197606693
VISIT DATE: 07/22/2021
NARRATIVE
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Bathrooms: At 10:00am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 120.1F. LPA observed appropriate grab bar and had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Trash can in bathrooms need lids to protect from cross contamination.
Common Areas: The facility maintains a comfortable temperature at 75F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher in the kitchen area and was last serviced on 10/21/20.
Surrounding Grounds: LPA toured the outside area of the facility. LPA observed various items stored in the backyard which need to be stored out of the way. LPA observed a ladder, a stack of wood beams, old commode and television. There are no bodies of water. Gate was unlocked and easily accessible to open. There is no appropriate shaded and seating area for residents outside. The Administrator has agreed to obtain appropriate outdoor furniture (table , chairs and umbrella for shade).
The garage is attached to the home and is kept locked inaccessible to residents.
Medications: Medications are centrally stored, however when the team arrived the cabinet was not locked and accessible to residents.
Administrative: LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC.500. Annual fees are not current and were discussed for payment. PIN and Fee amount was provided to the Administrator. The Administrator was advised to send proof of payment by 07/23/21. Moreover, the Administrator was advised to submit updated Liability Insurance.

Deficiencies issued per Title 22.

Appeal rights issued.

Exit interview

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/22/2021 01:48 PM - It Cannot Be Edited


Created By: Angela Panushkina On 07/22/2021 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 II
FACILITY NUMBER: 197606693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(7)(f)(1)(2)
87705 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).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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. Team observed the sharp knives and medication to be accessible to residents in care
This is an immediate health and safety risk to residents care.
POC Due Date: 07/24/2021
Plan of Correction
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The administrator has agreed to lock all the sharps and medication. This part of the plan of correction was met during the visit.
The administrator has agreed to provide training to all staff on the importance of maintaining medications inaccessible and keep all sharp items inaccessible. The administrator shall submit staff sign in shee with the topic and the training material.
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 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 (observation) , the licensee did not comply with the section cited above. The licensee failed to follow the infection control protocol on screening procedures. Staff were not familiar with screening procedures, none of the thermometers were operating properly and no symptom screening questions have been asked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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Licensee agreed to train all staff on Mitigation Plan and Infection Control which includes screening. Staff sign-in sheet and training materials shall be e-mailed to LPA (Angela.Panushkina@dss.ca.gov)
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/22/2021 01:48 PM - It Cannot Be Edited


Created By: Angela Panushkina On 07/22/2021 at 12:49 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 II
FACILITY NUMBER: 197606693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) facility did not have enough nonperishable foords for minimum of one week and perishable foods for a minimum of two days which poses an immediate health, safety risk to persons in care.
POC Due Date: 07/24/2021
Plan of Correction
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The Administrator has agreed to go grocery shopping and the copy of the receipt shall be emailed to LPA
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/22/2021 01:48 PM - It Cannot Be Edited


Created By: Angela Panushkina On 07/22/2021 at 12:57 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 II
FACILITY NUMBER: 197606693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(3)

87468.1 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:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.


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 by keeping the food locked and inaccessible to residents in which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 07/29/2021
Plan of Correction
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Licensee agreed to remove all the locks from the cabinets and provide staff training on Personal Rights. Appropricate Care and Supervision needs to be provided. Staff sign-in sheet and copy of training materials will be emailed to the LPA
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. Autditorial device in an entry door and room #3 were in poor repair and non operational, which poses a potential health, safety risk to persons in care.
POC Due Date: 07/29/2021
Plan of Correction
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Licensee agreed to buy new alarm system for the doors and the copy of the receipt and proof of photos will be emialed to LPA
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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