197606738-9-15-2022-31-AS-SSTS-CJARWF-20220915132305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606738
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:23:53 PM

Document Has Been Signed on 09/15/2022 01:23 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:	AQUAMARINE RETIREMENT HOME		FACILITY NUMBER:	197606738
ADMINISTRATOR:	MARICAR MEDINA		FACILITY TYPE:	740
ADDRESS:	6523 W. AVENUE L-7		TELEPHONE:	(661) 943-3642
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Maricar Reyes, Adminstrator		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) Shira Stamps met with administrator Maricar Reyes for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:40 am and was greeted by caregiver Rudy Abrenica. One (1) resident was observed in the kitchen eating. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 12:00 pm. LPA informed the Administrator of the purpose of the visit. Infection control: LPA was unable to review the facility mitigation plan since there was no file found. LPA requested the mitigation plan to ensure the facility is following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitizer was available. A tour of the physical plant was conducted with the caregiver at 11:40am. The facility has six (6) bedrooms and three (3) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for five (5) non-ambulatory, one (1) bedridden in room two (2), and a hospice waiver for two (2). The facility currently has one resident on hospice and one bedridden resident. Living and dining LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 76°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:55 am. There are two (2) fire extinguishers, one (1) is located in the kitchen and one (1) is located in the bedroom hallway. Fire extinguishers were observed to be full and last serviced on 06/02/21. CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
	VISIT DATE: 09/15/2022

NARRATIVE

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Food Inspection
LPA conducted tour at the kitchen around 11:45 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed the knives and sharp object located in an unlocked draw accessible to residents in care. The caregiver immediately locked the draw. The Medication cabinet was located in a kitchen cabinet and was observed to be locked and inaccessible to residents in care.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational for each room. Bedroom #2 was observed to have half rails. Upon review of the resident file it was found that no prescription was found for bed rails.

Bathrooms
At 11:50 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 119.9 degrees F.

Laundry
LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.

Physical environment
LPA toured the outside area of the facility at 11:52 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Garage
LPA observed the garage to be attached to the facility and currently being used for storage and an extra freezer.
Administrative: LPA collected the LIC.500, client roster, and the mitigation plan. Annual fee is due on 9/28/22. An exit interview was conducted, citations issued, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2022 01:23 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. 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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that they did not obtain a written order from a physician indicating the need for half bedrails for the resident located in Room #4, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2022
	Plan of Correction
1 2 3 4	The Administrator stated they will obtain a written physician order for half bedrails and will submit to the LPA by the POC due date.

Type B

Section Cited

CCR

87705(f)(1)

87705(f)(1) Care of Persons with Dementia. 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). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that they did not ensure the knives and sharp objects were inaccessible to residents in care. LPA observed the kitchen draw obtaining knives and sharp objects to be unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2022
	Plan of Correction
1 2 3 4	The Administrator stated they will provide training to all staff and provide LPA with the training material and signatures of all staff that have completed the training.

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	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/15/2022 01:23 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AQUAMARINE RETIREMENT HOME	FACILITY NUMBER: 197606738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

87309(a) Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that they did not ensure all cleaning solutions were locked and inaccessible. LPA observed the cleaning solution Comet in the unlocked bathroom cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2022
	Plan of Correction
1 2 3 4	The Administrator stated they will provide training to all staff and provide LPA with the training material and signatures of all staff that have completed the training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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