197606738-10-2-2024-31-AS-ERIS-D9NRXU-20241002132520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606738
Report Date: 10/02/2024
Date Signed: 10/02/2024 01:25:30 PM

Document Has Been Signed on 10/02/2024 01:25 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:	AQUAMARINE RETIREMENT HOME		FACILITY NUMBER:	197606738
ADMINISTRATOR:	MARICAR MEDINA		FACILITY TYPE:	740
ADDRESS:	6523 W. AVENUE L-7		TELEPHONE:	(661) 418-0715
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 4	DATE:	10/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Maricar Reyes		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above to conduct an annual required visit. LPA was greeted and granted access by staff #1 (S1). Staff #2 (S2) contacted the administrator Maricar Reyes and informed them LPA was at the facility. Maricar Reyes arrived at the facility and met with LPA at 11:16 a.m. LPA explained the reason for the visit. The facility has an approved fire clearance for five (5) non ambulatory and one (1) bedridden resident for a total capacity of six (6). Facility has a Hospice waiver for two (2). At 9:52 a.m. LPA conducted a tour of the physical plant of the facility inside and out and the following was observed: Common Areas: These include the sitting room, living room dining area. Areas were observed clean and clear of clutter. The facility maintains a comfortable temperature at 77°F. There is a fire place that was adequately screened. The carbon monoxide detector was observed by the kitchen and living room. LPA tested carbon monoxide detector at 10:00 a.m. and observed it operational. There is one fire extinguisher observed fully charged with purchase date 10/13/2023. Auditory alarm on the sliding door leading to the backyard was observed non operational. Kitchen: The kitchen was observed clean with sufficient supply of two-day perishables and seven-day non-perishables foods; properly stored. LPA observed the knives and sharp objects located in a locked kitchen drawer inaccessible to residents in care. Bathrooms: LPA toured three resident bathrooms. One (1) bathroom is located in a resident's bedroom for private use. All bathrooms were observed with non-skid matts, grab bars, toilet paper, paper towels and hand soap/ hand sanitizer. Hot water was tested at 10:05 a.m. and measured within regulation. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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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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: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
	VISIT DATE: 10/02/2024

NARRATIVE

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Bedrooms: LPA toured five (5) resident bedrooms. LPA observed rooms to have appropriate bedding and lighting. There is a night stand and sufficient storage. LPA tested the auditory alarms on the exit doors in the bedrooms and it they were observed to be either non operational or switched off in each room.

Laundry/Garage: LPA observed chemicals/hazardous items in a locked cabinet in the laundry room inaccessible to residents in care. The laundry room leads to the attached garage that is used to to store extra food in a freezer and for storage.

Outside: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

At 11:37 a.m. S1 tested smoke detectors located throughout the facility. LPA observed smoke detectors to be functioning properly.

Resident and Staff Files: At approximately 10:45 a.m. LPA reviewed resident and staff files. LPA conducted a file review of four (4) out of four (4) resident records to insure compliance of licensing forms. LPA review of Resident #1's (R1's) file revealed R1 was found by staff weak and not alert, EMS was called and transported R1 to the hospital. R1 was admitted on 08/4/2024 and discharged from the hospital on 08/06/2024. LPA review of Unusual Incident Reports to CCL revealed none for the incident had been submitted by the facility. LPA also conducted a file review of two (2) staff records to insure forms and training are up to date and in compliance with licensing forms. LPA observed S1's and S2's first aid certification past renewal date of June 10, 2024. S2 informed LPA certification is expired a that they would renew certification. LPA reviewed emergency disaster training, LIC 500 and facility program.

Medications: At approximately 12:00 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a kitchen cabinet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). LPA also observed a complete first aid kit with manual.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there were deficiencies observed during today's visit (refer to LIC809-D). Exit interview conducted. Appeal rights and copy of the report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/02/2024 01:25 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: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's review of resident #1's (R1's) file revealed an Unusual Incident Reports was not submitted to CCL when R1 was transported to the hospital by EMS and discharged from the hospital on 08/06/2024, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee will review regulation cited and submit a statement of understanding to LPA by POC due date 10/18/2024.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA review of two (2) staff files revealed they did not have renewed first aid and CPR training/certification on file and were the only two staff observed providing care to residents during time of visit, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee will submit copies of renewed First aid CPR of staff to LPA by POC due date 10/18/2024.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC809 (FAS) - (06/04)

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