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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608079
Report Date: 03/02/2022
Date Signed: 03/02/2022 01:26:50 PM


Document Has Been Signed on 03/02/2022 01:26 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:HEIGHTS SENIOR CARE, THEFACILITY NUMBER:
197608079
ADMINISTRATOR:SAYDA NAZ HAIFACILITY TYPE:
740
ADDRESS:690 PICAACHO DRIVETELEPHONE:
(562) 228-3063
CITY:LA HABRA HEIGHTSSTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 5DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sayda Hai TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food, and medication review. LPA Flores met with Syda Hai administrator and explained the reason for the visit.

Facility is licensed to serve 6 residents, of which 5 can be non-ambulatory and 1 can be bedridden. Facility is in a residential neighborhood and is two stories home, first floor consist of a kitchen, living room, family room, 3 resident rooms, 2 bathrooms, 1 staff room, an attached garage. The Basement is the administrator's residential area and inaccessible to the residents. NO bodies of water were observed. Smoke detectors were tested and are in working condition.

LPA Flores conducted a tour of the facility with Sayda Hai administrator and conducted a tour of the facility. Kitchen was observed, facility has sufficient food for at least 2 days worth of perishables and 7 days of non-perishables. Knives and cleaning supplies are kept under lock in the kitchen. Medication cabinet is located in the dining room and observed to be lock. LPA reviewed medication for resident #1(R1) and #2(R2). Each bedroom has sufficient lighting, furniture, and bedding supplies. Water temperature was tested in bathroom #1 and #2 at 105.0 degrees F. which is within the required 105-120 degrees F. Flies were reviewed for R1,R2, staff #1, and #2. LPA reviewed file for staff #2 which was missing health screening/TB test. Facility must update visitor's log to include screening questionnaire, and temperature log. Signs are posted in bathrooms and throughout the facility. PPE supplies were observed for at least 30 days. Staff have not been fit tested for N95 mask. Administrator Certificate was observed for Sayda Hai 6015618740 expiration date: 4/14/22.

Deficiencies have been noted in LIC 809D per Title 22 Chapter 6 Division 8, and technical advisories have been noted.
Exit interview was conducted with Sayda Hai and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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 03/02/2022 01:26 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: HEIGHTS SENIOR CARE, THE
FACILITY NUMBER: 197608079

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 as staff #2 did not have a health screening on personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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Administrator will ensure staff #2 obtains a health screening and provides a copy to the department by 3/9/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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