197607136-7-18-2024-28-AS-TRES-D7AU7J-20240718152001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607136
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:20:33 PM

Document Has Been Signed on 07/18/2024 03:20 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	FOREVER YOUNG		FACILITY NUMBER:	197607136
ADMINISTRATOR:	MARTINIANA LAURETA		FACILITY TYPE:	740
ADDRESS:	1059 S. WINDSOR BL.		TELEPHONE:	(323) 933-5051
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90019
CAPACITY:	6	CENSUS: 6	DATE:	07/18/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Licensee/Administrator Martiniana Laureta		TIME COMPLETED:	03:20 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) Tyler Reyes conducted a case management visit in order to reissue citations for deficiencies observed during the annual inspection visit conducted on 05/30/2024. LPA Reyes met with Licensee Laureta and explained the reason for the visit.

On 5/30/24 LPA Reyes conducted an unannounced required annual inspection. During the review of medications, LPA Reyes observed that the medication for Resident 1 (R1) was not administered according to the physician’s prescribed instructions. There were instances where medication was not administered on the scheduled dates and the medication sheet for May 2024 showed not all doses were documented.

Based on LPA Reyes's review of R1’s Medication Sheet for the month of May 2024. LPA Reyes observed R1s medications were still inside the Bubble Pack and the May 2024 Medication Sheet was initial by staff as medication were administered, therefore staff did not administer R1s medications per physician orders for R1s medications listed below. Staff 1 (S1) stated to LPA that the reason for not administering or documenting the missed medication for the May 2024 Medication Sheet was just missed.

· R1’s AM Medication –Simethicone 80MG (Take 1 Tablet By Mouth 4 Times Daily) were still in the bubble pack for the following dates: 05/01/24 through 05/22/24, 05/24/24 and 05/30/24, .

· R1’s AM Medication - QUEtiapine Fumarate 50MG (Take 1 Tablet By Mouth Daily) were still in the bubble pack for the following dates: 05/01/24 through 05/17/24, 05/22/24 through 05/24/24, and 5/30/24.

Refer to LIC 809C for continuation of report

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG	FACILITY NUMBER: 197607136
	VISIT DATE: 07/18/2024

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
26
27
28
29
30
31
32

·R1’s Noon Medication - Simethicone 80MG (Take 1 Tablet By Mouth 4 Times Daily)were still in the bubble pack for the following dates: 05/01/24 – 05/25/24,

· R1’s PM Simthicone 80MG (Take 1 Tablet By Mouth 4 Times Daily) were still in the bubble pack for the following dates 05/01/24 through 05/24/24 and 05/29/24.

· R1’s Bedtime Mediation - Melatonin 5MG (Take 1 Tablet By Mouth Daily) were still in the bubble pack for dates 05/01/24 through 05/05/24, 5/13/24 through 05/16/24, 5/21/24 through 05/24/24, and 5/29/24.

· R1s Bedtime Medication Simethicone 80 MG (Take 1 Tablet By Mouth 4 Times Daily)were still in the bubble pack for the following dates: 05/01/24 through 05/25/24 and was still in R1’s bubble pack.

During 05/30/24 visit, LPA Reyes collected copies of R1’s file and pictures of R1’s missed medication.

Licensee Laureta provided LPA Reyes with the following documents in-service training for all staff on medication, and that R1’s physician was notified on 5/31/24.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809D for details. Exit interview was conducted with Licensee. Licensing report and appeal rights were discussed and provided to facility Licensee.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 07/18/2024 03:20 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: FOREVER YOUNG	FACILITY NUMBER: 197607136
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 07/18/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical Care (c) resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Licensee reprovided LPA Reyes with the following documents in-service training for all staff on medication, and that R1’s physician was notified.
	8 9 10 11 12 13 14	Based interview and record review of medications conducted on 5/30/24, LPA Reyes observed that the medication for Resident 1 (R1) was not administered according to the physician’s prescribed instructions. There were instances where medication was not administered on the scheduled dates and the medication sheet for May 2024 showed not all doses were documented. Staff 1 (S1) stated to LPA that the reason for not administering or documenting the missed medication for the May 2024 Medication Sheet was just missed.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler Reyes	TELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3