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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608489
Report Date: 07/26/2022
Date Signed: 07/26/2022 06:21:56 PM


Document Has Been Signed on 07/26/2022 06:21 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:DIGNITY CARE HOME #1FACILITY NUMBER:
197608489
ADMINISTRATOR:RONALD M. VIRAYFACILITY TYPE:
740
ADDRESS:8821 VALJEAN AVENUETELEPHONE:
(818) 891-1222
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Raymond M. VirayTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's), Yelena Avetisyan and Evelin Rios, conducted an unannounced Required 1 Year inspection. Upon arrival LPA's met with the staff who contacted the administrator via telephone. Administrator Raymond M. Viray arrived approximately 10::45 am.

At approximately 10:35 am LPA's observed staff 2 (S2) walk outside the facility towards the exit door located in the office area and unlock the exit door from the outside.

Approximately 10:40 am LPA's conducted physical plan inspection and observed the following.
BEDROOMS: The five resident bedrooms had appropriate furnishings, clean linens and sufficient lighting. While touring the rooms at approximately 10:42 am LPA's observed half rail placed on bed in room # 1, room # 2, Room # 3 and room #5. LPA's also observed full rail being utilized in room # 5. LPA's also observed exit doorknob in room #5 with a cover to prevent the door from opening. LPA's also observed The LPA's conducted review of resident and hospice files and did not observe physicians orders for the half rails. Review of hospice care plan for resident #5 did not indicate the need for the full rails. Approximately 10:42 am while conducting physical plant tour LPA's briefly spoke with Staff 1 (S1) who informed the LPA's that they reposition Resident 1 (R1)Resident 2 (R2), Resident 3(R3). RESTROOMS: Restrooms (2) were clean and sanitary with grab bars and non-skid surfaces. The LPA observed hand washing signs in all restrooms. At approximately 10:52 am while touring the office area LPA's observed a second fire extinguisher that was inspected/serviced on 1/11/2019

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable but did not have sufficient 7 day supply of non-perishable food. At 10:58 am while touring the kitchen LPA's observed the fire extinguisher was serviced on 1/11/2019.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by admitting/retaining 4 bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee / Administrator will submit LIC200 and Facility Sketch. Facility sketch will need to specify rooms for bedridden residents or submit a dated, signed written statement notifying the department how this deficiency will be corrected. This is a zero tolerance violation, therefore, a civil penalty in the amount of $500.00 has been issued. Civil penalty in the amount of $100.00 per day will continue to accrue until POC is received.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above by not ensuring staff receive the required annual training poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee / Administrator will need to schedule 40 hours vendorized training for all staff. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/27/2022 and completion of training by 8/12/2022.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above by not providing medication training to all staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
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Administrator will schedule vendorized medication training for all staff. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/27/2022 and completion of training by 8/12/2022.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not ensuring a current hospice care plan which indicated the need for a full rail is obtained for R5 which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 07/27/2022
Plan of Correction
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Licensee/Administrator will obtain a current hospice care plan which indicates the need for the full rail being utilized by R5. and submit Copy of the plan to the Department as POC.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation a, the licensee did not comply with the section cited above by not conducting/documenting routine symptom screening for staff and visitors which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee/Administrator will schedule training for all staff to be provided by and individual certified in infection control infection prevention, symptoms, transmission and PPE use, and all sections listed in the department LIC808 Mitigation Plan. Verification of the completed training will need to be submitted as POC.
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

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 by not ensuring staff are fit tested for N95 masks as required and indicated in the licensees mitigation plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee/Administrator will schedule fir testing for all staff including licensee and administrators. Licensee/Administrator will documentation to confirm all staff including the licensee representative and administrator were fit tested fro N95 masks.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(d)
Admiistrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, and citation issued during the visit, the licensee did not comply with the section cited above by not ensuring the administrator has knowledge of and ability to conform to the applicable laws rules and regulations, which poses a potential health and safety and personal right risk to persons in care
POC Due Date: 08/12/2022
Plan of Correction
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The administrator will attend additional 20 hours of training related to the operation of the facility and deficiencies cited in this report. Administrator will submit a written explanation why the facility is currently operating non-compliant with applicable laws, rules and regulations.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 by not maintaining current records for 4 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee/Administrator will complete files for all residents. Once completed licensee/administrator will submit a signed, dated self certification that all resident files have been, reviewed, updated and complete as required by the cited regulation.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the required postings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee/Administrator will review the regulation and Post all the required postings at the facility. Once posted licensee will submit a photo of the required postings as a POC.
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having sufficient supply of non-perishable food at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee/Administrator will purchase non-perishable food for the facility, copy of the receipt and photo of the purchased food will need to be submitted as POC.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(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
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Based on medication and record review, the licensee did not comply with the section cited above by not documenting date and time PRN medications are taken. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee/Administrator will submit a written statement notifying how this deficiency will be corrected and what steps will be taken to ensure compliance with the cited regulation at all times.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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4
Based on interview, record review, the licensee did not comply with the section cited above by not completing/maintaining an updated Emergency Disaster Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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Licensee/Administrator will review the cited health and safety code, complete an updated Emergency disaster plan and submit copy of the plan to the Department as POC.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by ensuring staff receive training specific to bedridden residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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2
3
4
Licensee/administrator will schedule and complete training for all staff, verification of staff training with the trainers credentials will need to be submitted as POC.
Type B
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 by utilizing half bed rails for 4 residents without a written order from the physician which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2022
Plan of Correction
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3
4
Licensee/Administrator will contact the physicians and obtain order for postural support for all residents and submit copies of the orders to the department as POC.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having an annual medical assessment for 1 out of 6 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
1
2
3
4
Licensee/Administrator will obtain updated physicians report for all resident whose physicians reports were completed prior to 08/2021 and submit copies to the Department as POC.
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489
VISIT DATE: 07/26/2022
NARRATIVE
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COMMON SPACES: The facility maintained a comfortable temperature. Required postings were observed on the front door. The backyard had furniture and a covered area for resident use. The facility has an in ground swimming pool which was appropriately fenced. At approximately 10:50 am LPA's observed both pool gates/doors to be unlocked at the time of the visit.

At approximately 11:00 am LPA's conducted interview with LVN from Ann Hospice regarding the 5 residents who are receiving hospice care from their agency.

INFECTION CONTROL: The licensee has a central entry point for universal screening and temperature checks, the staff did not ask the LPA's screening questions nor were the LPA’s temperature taken at the time of the visit. Additionally Staff did not perform symptom screening or temperature check for hospice staff. There were COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available for use throughout the facility. The facility’s cleaning protocol is sufficient. The licensee can designate a single-person room to isolate persons if there is a confirmed case of COVID-19 Staff are up to date regarding guidelines around visitation and vaccine requirements. Licensee/Administrator did not provide staff training on their mitigation plan, did not provide staff infection control training and did not provide N95 fit testing as required.

From Approximately 11:30 am LPA's conducted review resident and staff records.

  • Resident records reviewed revealed the following.
  • Licensee did not have complete file for 4 out of 6 residents.
  • Licensee is currently retaining 5 residents on hospice, but has and approved hospice waiver for 4 residents.
  • Based on review of records, resident, staff and hospice staff interviews 4 out of 6 resident are Bedridden.
  • Licensee does not have current physicians report for R3 who has a diagnosis of Major Neurocognitive disorder. Physicians report for other 5 residents were outdated and did not reflect changes in the residents conditions.


Staff files were complete with all required documents, however staff did not have the required annual and medication training. A discussion was held with the licensee regarding the training requirements.
The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22. Exit interview conducted, a copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 19
Document Has Been Signed on 07/26/2022 06:21 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee/administrators did not comply with the section cited as the 2 fire extinguishers were serviced/inspected 1/11/2019 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
1
2
3
4
Licensee/Administrator will have purchase new fire extinguisher or have the existing ones serviced Licensee/administrator will submit documentation to confirm servicing of the fire extinguisher or submit photo and receipt confirming purchase of a new fire extinguisher. This is a zero tolerance violation therefore a civil penalty in the amount of $500 dollars has been assessed/issued. Civil Penalty in the amount of $100 dollars per day will continue to accrue until POC has been received.
Type A
Section Cited
CCR
87705(I)(5)
The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:
(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and interview, the licensee did not comply with the section cited above securing exit doorknobs and key locking exit door in the office area preventing the doors from opening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
1
2
3
4
Administrator removed the doorknob cover during the visit, administrator will need to remove the key lock from the office exit door. Administrator will submit photo of the removed lock and provide a signed statement of understanding and intent to abide by the cited regulation. This is a zero tolerance violation therefore a civil penalty in the amount of $500 dollars has been assessed/issued. Civil Penalty in the amount of $100 dollars per day will continue to accrue until POC has been received.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 10 of 19


Document Has Been Signed on 07/26/2022 06:21 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DIGNITY CARE HOME #1
FACILITY NUMBER: 197608489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(e)
Swimming pools and other bodies of water shall be fenced and in compliance with State and local building codes

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, as the gates leading to the swimming pool were not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2022
Plan of Correction
1
2
3
4
The licensee ensured that the gate was locked immediately. Licensee will need to submit a written statement of understanding.
This is a zero tolerance violation therefore a civil penalty in the amount of $500 dollars has been assessed/issued. Civil Penalty in the amount of $100 dollars per day will continue to accrue until POC has been received.
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 19