197607223-10-12-2024-31-AS-ALOZ-D9YRJ4-20241012130318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607223
Report Date: 10/12/2024
Date Signed: 10/12/2024 01:03:35 PM

Document Has Been Signed on 10/12/2024 01:03 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
Lookup Error,
, CA

FACILITY NAME:	ARDENVILLE HOME CARE I		FACILITY NUMBER:	197607223
ADMINISTRATOR:	VICENTE A. ROBLES		FACILITY TYPE:	740
ADDRESS:	7747 SHADYCOVE		TELEPHONE:	(818) 767-6054
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Vincent A Robles, Administrator		TIME COMPLETED:	01:19 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) Alberto conducted the required annual inspection. LPA arrived unannounced and met with Administrator Vincent Robles who allowed entry of the facility and explained the purpose of the visit. Shortly after the Licensee Arden Robles arrived and assisted with the visit. The facility is licensed for residents ages 60 and over, may retain a maximum of four (4) hospice residents. Currently facility has 4 hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: The Infection Control Plan has been added to the Operation Plan. A Hospice Waiver for 4 residents is approved. Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 2 residents are currently bedridden according to most recent LIC602A. Facility is not licensed for any bedridden. 3. Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes Dining area, kitchen, sitting room, six residents bedrooms, two resident bathrooms, one guest bathroom, laundry room, detached garage. Each resident bedroom has one bed, dresser, required beddings and furniture and sufficient lighting and closet space. The two residents bathrooms are clean, sanitary and in a good working condition. Both bathrooms have the required grab bar but not non-skid mat. The two bathrooms hot water temperature were tested between 112.2 and 116.4 degrees F. which is within the Tittle 22 regulation. All the appliances in the kitchen and living room are working well. The sharp knives are stored in a locked kitchen drawer. (Continue on 809C)

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

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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Document Has Been Signed on 10/12/2024 01:03 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
Lookup Error,
, CA

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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. facility is retaining two (2) bedridden residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2024
	Plan of Correction
1 2 3 4	Licensee will obtain a proper fire clearance for the bedridden residents. Submit application for the 3 bedridden residents.

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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. The facility did not have slip mats which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee will purchase Non-skid mats or strips for the residents showers by POC date.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2024 01:03 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
Lookup Error,
, CA

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) 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. The cleaning solution were accessible to resident which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee locked cleaning solution during the visit. *NO FURTHER ACTION REQUIRED**

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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. R1 and R5 had PRN without labels] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee will obtain doctor's and labels for R1 and R5

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2024 01:03 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
Lookup Error,
, CA

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87618(b)(3)(A)

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. 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. Two residents currently use oxygen which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee will make written report to local fire jurisdiction that oxygen is in use at the facility.

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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. One resident had full bedrails without doctor's orders which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2024
	Plan of Correction
1 2 3 4	Licensee will obtain doctor's order for residents that use bedrails and send POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
	VISIT DATE: 10/12/2024

NARRATIVE

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All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room area LPA observed the cabinet unlocked during visit. The linen and towels are stored in the hallway cabinet. The extra personal hygiene products are stored in the resident’s room. The carbon monoxide detectors were inspected, and they are working properly. The facility has table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction.

4. Staffing: The facility has sufficient staffing, and the night supervision staff.

5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current.

6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan.
7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours are included in admission agreement.
8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept very clean and free from rodents.
10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the kitchen. six (6) centrally stored resident medications were reviewed, which contained 30-day supply of medications. R5 did not have doctor’s order or label. Family will provide transportation to resident for medical and dental appointment if needed.
11. Disaster Preparedness: The last fire drill was conducted on 07/02/24. Records of resident Appraisal and Needs services plans are part of Emergency training. The facility has an Emergency Disaster Plan (LIC610E) dated on 06/02/2007 that needs to be updated. The facility has two alternative temporary shelter location.
12. Resident with Special Health Needs: Two (2) residents are receiving home health services. four (4) receive hospice care. No resident is currently on postural support. Half and full bed rails for mobility assistance were observed in resident rooms without physician order. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions.

Deficiencies observed during today’s visit. Technical Advisory provided. An exit interview was held. A copy of this report, two technical advisory notes, and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024

LIC809 (FAS) - (06/04)

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