197607590-11-19-2023-28-AS-KRAZ-CXQVXJ-20231119154936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607590
Report Date: 11/19/2023
Date Signed: 11/19/2023 03:50:03 PM

Document Has Been Signed on 11/19/2023 03:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HERITAGE HOME CARE		FACILITY NUMBER:	197607590
ADMINISTRATOR:	NINO S. NAVARRO		FACILITY TYPE:	740
ADDRESS:	4146 ATLANTIC CIRCLE		TELEPHONE:	(626) 272-1540
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 6	DATE:	11/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Nino Navarro		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/19//2023.
LPA was met by Administrator Nino Navarro and explained the purpose of the visit. The facility is licensed to serve six (6) non ambulatory residents over the age of 60 and has an approved hospice waiver for five (5).

LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located under kitchen sink, to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 129.2 degrees F. LPA Ramirez will issue Technical Violation. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Nearby thermostat was observed to read 74 degree F.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 5: LPA Ramirez inspected five (5) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.

Bathrooms: Water temperature in three (3) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked.

See 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

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 11/19/2023 03:50 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE HOME CARE	FACILITY NUMBER: 197607590
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, four out of six residents medications were not stored in origanl container before being administered to residents, the licensee did not comply with the section cited above in 4 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	Licensee will not "set up" medications from original container into another container. Licensee will re-train staff and send proof of re-training of all staff by 12/04/2023.

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HERITAGE HOME CARE	FACILITY NUMBER: 197607590
	VISIT DATE: 11/19/2023

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Centrally Stored Medications: Was observed to inaccessible to six (6) out of six (6) residents in care. LPA Ramirez reviewed six (6) out of the six (6) resident medications. LPA Ramirez observed four (4) out of the six (6) resident medications, to be stored in a different container, and not in original container. Per Administrator Nino Navarro, staff sets up resident medications for AM, noon time, PM and bedtime. LPA Ramirez will issue Type B deficiency.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: Last documented drill was conducted on 09/18/23 at 10:15 am and 6/2/23 at 10:35 am.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. LPA Ramirez observed several fully charged fire extinguishers throughout the facility.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff.

Resident Files: Six (6) resident files were reviewed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.

Attached Garage: LPA Ramirez observed emergency water and food supply in this area. Washer/dryer and extra cleaning supplies are located in garage. Access to garage was observed to be inaccessible to six (6) out of six (6) residents in care.

One (1) deficiency is being cited and one (1) Technical Violation is being cited. Exit interview was conducted with Administrator Navarro and a copy of this report, 809-D, LIC 9102 and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023

LIC809 (FAS) - (06/04)

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