197609338-10-14-2024-31-AS-ERIS-DA2TAM-20241014143346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609338
Report Date: 10/14/2024
Date Signed: 10/14/2024 02:33:55 PM

Document Has Been Signed on 10/14/2024 02:33 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:	B & M CARE FOR ELDERLY INC		FACILITY NUMBER:	197609338
ADMINISTRATOR:	ARAYATA, NATIVIDAD		FACILITY TYPE:	740
ADDRESS:	44851 MARIPOSA DRIVE		TELEPHONE:	(661) 942-2572
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	10/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Natividad Arayata		TIME COMPLETED:	02:40 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 conducted an unannounced Annual Inspection. Upon arrival LPA was greeted by staff #1(S1) and granted access. S1 contacted the administrator to inform them LPA was at the facility. Administrator, Natividad Arayata and administrator designee Marti Arayata met LPA shortly after. LPA explained the purpose of the visit. The facility has an approved fire clearance for six (6) non ambulatory residents of which one (1) may be bedridden in bedroom #1. Facility has a hospice waiver for four (4). At 10:00 am, LPA conducted a physical plant tour of the facility an observed the following. Bedrooms: There are five (5) total resident bedrooms and one (1) is shared. All bedrooms have the proper furniture and adequate lighting. The auditory alarms on each exit door was tested and found to be operational. When LPA tried to access bedroom #2 the Administrator designee had to unlock the bedroom door. The bedroom is currently vacant. Inside LPA observed an exiting door with a bent screw or bolt holding it closed. Screw was removed and LPA was able to open it to test auditory alarm. LPA observed the same holes where a screw is placed to keep the door closed by the front door of the facility. LPA discussed the observation with the administrator. Administrator explained they understood it was against regulation, but they have been having an issue with resident #1(R1) constantly trying to leave the facility without supervision. The screw is used to keep resident #1(R1) from leaving when staff cannot accompany them or convince them to stay. R1 confirmed they are not able to leave through the front door because something is preventing the door from opening. Administrator stated they would not be obstructing the door moving forward and will discuss this with there staff. Bathrooms: There are three (3) bathrooms and one (1) is inside the shared bedroom for private use. Each bathroom is equipped with grab bars and non-slip mats. The hot water temperature was taken at 11:00 a.m. from one (1) bathroom and read 113 degrees Fahrenheit 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: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

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: B & M CARE FOR ELDERLY INC	FACILITY NUMBER: 197609338
	VISIT DATE: 10/14/2024

NARRATIVE

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Laundry room/Garage: Laundry room is kept locked. Chemicals such as laundry detergents are also locked and stored above the washer and dryer. The garage is attached and access to the garage is through the laundry room. Garage is used to store furniture, facility supplies, and has a deep freezer for extra food.
Common Areas: These include the living room and dining areas. Areas were clean and clear of clutter furniture was observed to be in good repair. Fireplace in the living room was secured with a screen. Couches and chairs sit the capacity of the facility. Smoke and Carbon Monoxide detectors were tested at 11:35 a.m. and observed operational.

Kitchen: The kitchen was observed clean and clean of clutter. Knives and sharps are locked in a kitchen drawer inaccessible to residents. Chemicals for cleaning are locked and stored underneath the sink. LPA observed that the facility had a sufficient amount of perishable and nonperishable foods. LPA observed a facility telephone accessible to residents. Fire extinguisher was observed fully charged with purchase date 07/08/24.

Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water. The surrounding grounds were clean, organized, and free from any obstructions. Facility has one shed outside that is used for additional storage.

Facility/Staff Files: At 11:23 a.m. LPA reviewed the facility's personnel schedule (LIC500), client roster, Certificate of Liability Insurance, Fire Clearance, Emergency Disaster Plan and Infection Control Plan. At 11:35 a.m. LPA reviewed four (4) staff records to insure forms and training are up to date and in compliance with licensing forms.

Resident Files: At 12:10 p.m. LPA reviewed two (2) of two (2) resident records to insure compliance of licensing forms. Review of R1's file revealed a diagnosis of Dementia. Medication: Medication is centrally stored in the kitchen and was observed locked. LPA and Administrator reviewed medication and medication records at 12:56 p.m. Facility has a fully supplied first aid kit with manual.

Deficiency observed on todays visit (refer to LIC809-D). Exit interview conducted. A Copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2024 02:42 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/14/2024 02:36 PM

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: B & M CARE FOR ELDERLY INC	FACILITY NUMBER: 197609338
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(l)(2)

Care of Persons with Dementia

(l) 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 observation, licensee did not comply with the regulation as the front door and exterior door in bedroom #2 were obstructed by a bent screw or bolt which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Administrator removed the screw and confirmed that she would inform her staff not to obstruct the exit doors. Licensee agreed to submit a statemet of understanding on the regulation cited and conduct an in-service training on the facility's program "Supplemental Information to Provide Care for Persons with Dementia" and submit sign in sheet to LPA 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024

LIC809 (FAS) - (06/04)

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