197608294-10-4-2024-31-AS-ERIS-D9QSA3-20241004134140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608294
Report Date: 10/04/2024
Date Signed: 10/04/2024 01:41:49 PM

Document Has Been Signed on 10/04/2024 01:41 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	J.R. RETIREMENT HOME FOR ELDERLY		FACILITY NUMBER:	197608294
ADMINISTRATOR:	JEFFERSON L. REYES		FACILITY TYPE:	740
ADDRESS:	44035 22ND STREET WEST		TELEPHONE:	(661) 951-0994
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	10/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jefferson Reyes		TIME COMPLETED:	01:55 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) Evelin Rios arrived at the facility above to conduct an annual required visit. LPA was greeted and granted access by staff #1 (S1). S1 contacted the administrator Jefferson Reyes and informed them LPA was at the facility. LPA explained the reason for the visit. Jefferson Reyes arrived at the facility and met with LPA. The facility has an approved fire clearance for five (5) non ambulatory and one (1) bedridden resident for a total capacity of six (6). Facility has a Hospice waiver for two (2). At 9:06 a.m. LPA conducted a tour of the physical plant of the facility inside and out and the following was observed: Kitchen: The kitchen was observed clean with sufficient supply of two-day perishables and seven-day non-perishables foods. LPA observed the knives and sharp objects located in a locked kitchen cabinet inaccessible to residents in care. Common Areas: These include living area and dining area. Areas were observed clean and clear of clutter. The facility maintains a comfortable temperature at 76°F. There is a fire place that was adequately screened. There are (2) carbon monoxide detector one (1) in the kitchen and one (1) living area. LPA tested carbon monoxide detector by the living area at 9:08 a.m. and observed it operational. There is one fire extinguisher observed fully charged with purchase date 10/11/2023. Auditory alarm on the sliding door leading to the backyard was observed functional. Bathrooms: LPA toured two resident bathrooms. One (1) bathroom is located in a shared bedroom for private use. All bathrooms were observed with non-skid matts, grab bars, toilet paper, paper towels and hand soap. Hot water temperature was tested at 9:14 a.m. and measured at 109.3°F, within regulation. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J.R. RETIREMENT HOME FOR ELDERLY	FACILITY NUMBER: 197608294
	VISIT DATE: 10/04/2024

NARRATIVE

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Bedrooms: LPA toured four (4) resident bedrooms. Two (2) bedroom may be shared. LPA observed rooms to have appropriate bedding and lighting. There is a night stand and sufficient storage. LPA tested the auditory alarms on the exit doors in the bedrooms and they were observed operational.

Laundry/Garage: LPA observed chemicals/hazardous items in a locked cabinet in the laundry room inaccessible to residents in care. The laundry room leads to the attached garage that is used to store extra food in a deep freezer and for storage.

Outside: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Resident and Staff Files: At approximately 9:40 a.m. LPA reviewed resident files. LPA conducted a file review of five (5) out of five (5) resident records to insure compliance of licensing forms. LPA observed half bed rails on resident #1's(R1's) bed and resident #2's(R2's) bed. LPA's review of R1 and R2's file revealed there is no written bed rail order from a doctor on file for both residents. At 10:18 a.m. LPA also conducted a file review of three (3) staff records to insure forms and training are up to date and in compliance with licensing forms. LPA reviewed emergency disaster training, LIC 500 and infection control plan. LPA discussed resident care plans with administrator.

At 10:45 a.m. administrator tested smoke detectors located throughout the facility. LPA observed smoke detectors to be functioning properly.

Medications: At approximately 10:50 a.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a kitchen cabinet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR).

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there was a deficiency observed during today's visit (refer to LIC809-D). Exit interview conducted. Appeal rights and copy of the report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2024 01:41 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J.R. RETIREMENT HOME FOR ELDERLY	FACILITY NUMBER: 197608294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 in two (2) out of five (5) residents with half bed-rails on their beds and not having a written doctor order on file for resdients which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2024
	Plan of Correction
1 2 3 4	Licensee removed bed rails on todays visit and will not add them until a doctor order is on file.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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