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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607831
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:21:16 PM


Document Has Been Signed on 12/15/2023 02:21 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MAUNA LOA OAKS "LLC"FACILITY NUMBER:
197607831
ADMINISTRATOR:LIUBOV SHEVTSOVAFACILITY TYPE:
740
ADDRESS:19041 E. MAUNA LOA AVE.TELEPHONE:
(626) 387-9186
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 4DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Liubov Shevtsova- AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Liubov Shevtsova, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (4) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (5) non-ambulatory residents and (1) bedridden resident. It has an approved Dementia Care Plan and a Hospice Waiver approved for (3) residents. There is currently (1) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are 1 full and one half bathrooms in the home- both equipped with required grab bars and non-skid mat for the shower. The hot water was tested and measured at 112*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 11/20/2023. Auditory devices were observed at all entrances/exits of the home. (4) of (4) resident files were reviewed and observed to be missing Functional Capabilities Assessments and Needs and Services Plans. (1) of (4) resident files were observed to be missing an updated medical assessment/Physician's Report, as required annually due to their cognitive impairment. (3) staff files were reviewed and had all the required documentation. (4) resident medications were reviewed and were observed to be documented properly and given as prescribed.
Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the attached LIC9099-D page.
Exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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 12/15/2023 02:21 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MAUNA LOA OAKS "LLC"
FACILITY NUMBER: 197607831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in (4) of (4) residents missing Needs and Services Plans and Functional Capabilities Assessments on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee to complete Functional Capabilities Assessments and Needs and Services plans for 4 residents in care. Email copies to LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in (1) of (4) residents in care missing an updated Physician' Report (medical assessment) as required annually, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee to obtain an updated Physician's Report for R1 and submit to LPA, via email, by POC due 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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