Community Care Licensing

Document Has Been Signed on 12/10/2021 01:10 PM - It Cannot Be Edited

FACILITY NAME:	BEECHNUT BOARDING		FACILITY NUMBER:	197607019
ADMINISTRATOR:	PETER RYAN GOZUN		FACILITY TYPE:	740
ADDRESS:	1220 BEECHNUT PLACE		TELEPHONE:	(909) 865-5838
CITY:	POMONA	STATE: CA	ZIP CODE:	91766
CAPACITY: 6		CENSUS: 4	DATE:	12/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Facility Administrator		TIME COMPLETED:	01:30 PM

SUPERVISORS NAME: Christine Yee LICENSING EVALUATOR NAME: Elizabeth Irra LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021

Link to Parent Document Below:

FACILITY NAME: BEECHNUT BOARDING	FACILITY NUMBER: 197607019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2021

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
	Deficient Practice Statement
1 2 3 4	This standard is not met as evidence by: S-1 and S-2 do not have a physician's report nor TB on file.
	POC Due Date: 12/11/2021
	Plan of Correction
1 2 3 4	Administrator to have all staff schedule their annual exams including TB test and submit proof of scheduled visit(s) and submit written statement as to how the Administrator will continue to comply with this requirement. Administrator to submit this information to LPA Irra by 12/11/2021.

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Elizabeth Irra LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021

Link to Parent Document Below:

FACILITY NAME: BEECHNUT BOARDING	FACILITY NUMBER: 197607019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2021

Type B

Section Cited

CCR

87458(c)

Medical Assessment. (c) The licensee shall obtain an updated medical assessment when required by the Department.
	Deficient Practice Statement
1 2 3 4	This standard is not met as evidence by: R-1 has a diagnoses of Dementia and the last Physician’s Report is dated 04/02/2020. R-2’s last Physician’s Report is dated 07/18/2017. R-3’s Physician’s Report is dated 02/28/2019 which noted R-3 has “memory loss and variable and slowly cognitively declining”.
	POC Due Date: 12/17/2021
	Plan of Correction
1 2 3 4	Administrator to have all Residents schedule a new Physician’s Report by 12/17/2021 and provide LPA proof of scheduled consultation and submit written statement as to how the Administrator will continue to comply with this requirement. Administrator to submit this information to LPA Irra by POC due date.

Type B

Section Cited

CCR

87465(f)(1)

Emergency care requirements shall include the following:(1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.
	Deficient Practice Statement
1 2 3 4	This standard is not met as evidence by: R-1 and R-3 LIC 601 are missing Physician and Dentist contact information. R-2 LIC 601 is missing dental contact information.
	POC Due Date: 12/17/2021
	Plan of Correction
1 2 3 4	Resident files require an updated LIC 601 and to include Residents Physician, Dental and other Medical Professionals contact information. Administrator to update the LIC 601 and submit proof of correction to LPA Irra by 12/17/2021.

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Elizabeth Irra LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021

Link to Parent Document Below:

FACILITY NAME: BEECHNUT BOARDING	FACILITY NUMBER: 197607019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2021

Type A

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Elizabeth Irra LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021

Link to Parent Document Below:

FACILITY NAME: BEECHNUT BOARDING	FACILITY NUMBER: 197607019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/10/2021

Type B

Section Cited

CCR

87465(f)(1)

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87466

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Christine Yee LICENSING EVALUATOR NAME: Elizabeth Irra LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021