197608079-2-13-2024-28-AS-JVIS-D2ERTK-20240213121827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608079
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:18:39 PM

Document Has Been Signed on 02/13/2024 12:18 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, THE		FACILITY NUMBER:	197608079
ADMINISTRATOR:	SAYDA NAZ HAI		FACILITY TYPE:	740
ADDRESS:	690 PICAACHO DRIVE		TELEPHONE:	(562) 228-3063
CITY:	LA HABRA HEIGHTS	STATE: CA	ZIP CODE:	90631
CAPACITY:	6	CENSUS: 5	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Administrator Sayda Naz Hai		TIME COMPLETED:	12:30 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 Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Sayda Naz Hai. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was not observed but requested

Physical Plant/Environment Safety:

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.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within title 22 regulations.

Operational Requirements:

A current Plan of Operation observed. Dementia Care Plan not on file
A fire clearance for total 6 residents of which (5) may be Non ambulatory and (1) bedridden
Hospice care waiver approved for up to three (3) residents.

Personnel Records - Staff Training:

Administrator on file is current
Staff have criminal background clearances.
Three (3) staff files were reviewed.

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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 4

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
	VISIT DATE: 02/13/2024

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

Staffing:

Sufficient staff observed during visit

Resident Records - Incident Reports:

A total of five (5) resident files were reviewed.

Resident Rights - Information

Required postings observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.

Incident Medical and Dental:

First Aid Kid observed
(5) of (5) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan observed
Last Emergency Drill conducted January 2024

Residents with Special Health Needs:

Currently (2) residents receiving hospice services. Hospice care plans observed

Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached

Exit interview conducted. Copy of this report and appeal rights were discussed and provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/13/2024 12:18 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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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) (interview) (record review)], the licensee did not comply with the section cited above as (5) of (5) resident medications were removed from their packaging and placed in weekly containers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/15/2024
	Plan of Correction
1 2 3 4	Licensee to schedule medication management training and provide LPA with date of training by POC due date. Once training is completed, Licensee to provide proof to LPA of training completion with names of staff who participated.

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/13/2024 12:18 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: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(c)

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited aboveas there was no dementia care plan in place which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2024
	Plan of Correction
1 2 3 4	Licensee to provide LPA with dementia care plan for the plan of operation by POC due date

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4