Community Care Licensing

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above per review of medications, HumulinN prescribed for Resident #4 was stored on the refrigerator door in a zip lock bag which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/01/2023
	Plan of Correction
1 2 3 4	Licensee will immediately take steps to ensure that the Humlin N is locked and secured so that it is inaccessible to the other residents in care by 9/1/23

Type A

Section Cited

CCR

87465(c)(1)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above per information provided by the Administrator, one resident has dementia and one is able to make own decision. However, the physician has not been contacted to make a final decision if either resident is or is not able to make their own decision which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	LIcensee will contact the prescribing doctors to obtain PRN Authorization Letters for all residents who are prescribed PRN medications and maintain in the residents' file

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type A

Section Cited

CCR

87465(d)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above since the Administrator has not established with the prescribing physician if Resident #5 is able to make own decision to request the medications other than the licensee's own observation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will contact the doctor for Resident #2 and Resident #5 each time the PRN medications are needed to obtain instructions from the physician, based on the the symptoms observed, whether the medication is to be dispensed until the PRN Authorizations can be obtained and a determination is made whether each resident can or cannot make their own decision for the PRN Medicatins by 9/7/23

Type A

Section Cited

CCR

87465(e)

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the facility does not have any physician's order on file for any of the centrally stored medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will contact the prescribing doctors for the centrally stored medications and obtain copies of the physician's orders and maintain in the residents' files by 9/7/23

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above per review of all 5 resident files reviewed. Resident #1 through Resident #4 have not had a annual reappraisal review since as far back as 2013 and 2018, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/14/2023
	Plan of Correction
1 2 3 4	Licensee will schedule a meeting with the resident and responsible parties to review and revised the written record by 9/14/23

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type B

Section Cited

HSC

1569.319(a)

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above per information provided by the Administrator that the facility has internet but does not have any computers, tablets, smart phone or any other devices available to dedicate for the residents' use. Only one resident has own computer which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	LIcensee will submit a plan of action as to how the facility will provide a dedicated device that can support real-time interactive applicatins for residents use by 9/7/23

Type B

Section Cited

HSC

1569.319(b)(1)

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (1) The device shall be available in a manner that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview the licensee did not comply with the section cited above and does not have a policy in place to address how the facility will make a device accessible to the residents in care to have discussions of personal or confidential information which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will come up with a tentative policy as to how the computer, tablet or other device will be made accessible to the residents for personal discussions or confidential information by 9/7/23

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type B

Section Cited

HSC

1569.319(b)(2)

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above as the facility does not have a policy in place as to how they will make the computer, tablet or other devices accessible among the residents in the facility during reasonable hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will include in the plan of action and tentative plan related to providing a computer, tablet or any other device as to how the device will be shared or made accessible to the residents during reasonable hours by 9/7/23

Type B

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited per review of the MAR logs reviewed. The Licensee is inconsistent about updating the MAR log when medications are dispensed. Per review of the August 2023 MAR log, medications dispensed from 8/24/23 through 8/31/23 were not updated. Also, MAR logs from March 22, 2022 through July 2023 were not maintained,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	Licensee will provide LPA Yee with a plan of action that will ensure that dispensed medications are updated daily on the MAR log and how MAR logs will be used 12 months a year to document dispensed medications by 9/7/23

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023

Document Has Been Signed on 08/31/2023 05:16 PM - It Cannot Be Edited

FACILITY NAME: EMVY BOARD AND CARE FACILITY	FACILITY NUMBER: 197608459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

Type B

Section Cited

CCR

87465(c)(3)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews, the licensee did not comply with the secction cited above per information provided, the facility does not document any dates of contact made with the physician, does not document the physician's instructions, the date the PRN's were dispensed, the dosage or the results of the dosage, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/07/2023
	Plan of Correction
1 2 3 4	The Licensee will come up with a plan as to how they will document the date of contact with the physician, the instructions provided, the date and time dosage was dispensed, the reactions/result of the medications and maintain it in the residents' file

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel TELEPHONE: (818) 596-4343 LICENSING EVALUATOR NAME: Christine Yee TELEPHONE: (747) 230-3890 LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023