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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608641
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:06:07 PM


Document Has Been Signed on 05/08/2024 04:06 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PINK CORAL RESIDENCE IIFACILITY NUMBER:
197608641
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:40343 N. 15TH STREET WESTTELEPHONE:
(661) 480-5985
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rey MedelTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by a caregiver and the Administrator. The facility is licensed as an adult residential facility for the elderly to serve three ambulatory residents, three non-ambulatory which includes one bedridden resident. The Administrator confirmed there are six residents living in the facility.

LPA and the Administrator began the tour of the facility at 9:30 am until 10:20 am. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating and a television.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. LPA observed the knives were locked in a kitchen drawer, and the cleaning solutions were locked in a cabinet underneath the sink.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, grab bars, slip resistant mats, paper towels, and a trash can. The water temperature was tested at 10:30 am and was 126 degrees F. The Administrator turned down the water heater temperature at 10:35 am.

Bedrooms – LPA Spaeth observed there are five residents' bedrooms in the facility. The bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Staff Room – LPA observed the staff room was locked.

Cont'd 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PINK CORAL RESIDENCE II
FACILITY NUMBER: 197608641
VISIT DATE: 05/08/2024
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Laundry Room/Garage – LPA Spaeth observed the laundry room was not locked and LPA observed medications were located in the unlocked area. The Administrator stated the medications were the Administrator's personal medications. LPA Spaeth advised the Administrator to lock the medications. At 10:15 am, LPA observed the Administrator locked the medications in the office room. LPA observed the washer and dryer were located in the room. The laundry detergent was locked in a room within the laundry room. LPA observed an additional staff room was located in the garage area.

Hallway Closet – LPA Spaeth observed a hallway closet contained additional clean linens. LPA observed another locked closet which contained additional PPE and hygiene items.

Backyard – LPA Spaeth observed comfortable seating in a shaded area. A locked gate surrounds the pool. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke/carbon monoxide detectors were tested at 10:30 am and are operational. .

LPA reviewed resident's records at 10:45 am until 11:45 am. LPA reviewed the staff records at 11:45 am until 12:15 pm.


The following deficiencies were issued (refer to LIC809D).

Exit interview conducted, appeal rights given, and a copy of the signed report was given to caregiver.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/08/2024 04:06 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PINK CORAL RESIDENCE II
FACILITY NUMBER: 197608641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's tour of the facility with the Administrator, the licensee did not comply with the section cited above. The laundry room was not locked and LPA observed a staff member's medication was not securely locked and was sitting out in the room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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During LPA's tour with the administrator, LPA observed the administrator locked the laundry room.
Type A
Section Cited
CCR
87303(e)
87303 Maintenance & Operation (e) Water Supplies & plumbing fixtures shall be maintained..(2) Faucets used by residents for personal care...shall deliver hot water. Hot water temperature controls shall be...a temperature...not more than 120 degrees F.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Administrator testing of the water temperature, at 10:30 am, the water temperature was 126.0 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2024
Plan of Correction
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LPA Spaeth and the caregiver tested the bathroom water temperature at 12:45 pm which was 120 degrees F. LPA advised the Administrator to test the water temperature on a monthly basis and keep a written report.
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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/08/2024 04:06 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PINK CORAL RESIDENCE II
FACILITY NUMBER: 197608641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(B)
87307 Personal Accommodations..(a)Living accommodations..shall be related to the facility's function (2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the designated office is being used as a resident room for a non-ambulatory resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The Administrator will move R2 from the designated office room to a non-ambulatory room.
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: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4