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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609345
Report Date:
10/16/2023
Date Signed:
10/16/2023 05:27:05 PM
Document Has Been Signed on
10/16/2023 05:27 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:
CASA AMORE
FACILITY NUMBER:
197609345
ADMINISTRATOR:
MORALES, RITA
FACILITY TYPE:
740
ADDRESS:
44124 WESTRIDGE DRIVE
TELEPHONE:
(661) 289-0288
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93536
CAPACITY:
6
CENSUS:
6
DATE:
10/16/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:48 AM
MET WITH:
Rita Morales
TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff #1 (S1). S1 contacted the administrator Rita Morales. Rita met LPA shortly after. LPA explained to the administrator the purpose of the visit. LPA observed required postings in the entry area. Administrator had to leave to an appointment and designated staff
Micaela Orozco
to sign for the report.
At 10:50 a.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed:
Kitchen:
The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen.
Bedrooms:
There are (4) bedrooms of which four (4) are designated for residents' use. Two of the bedrooms are shared. Rooms occupied by residents were properly furnished with appropriate bedding and linens and with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens, resident, staff records and medication.
Bathrooms:
There are two (2) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 11:15 a.m. and read between 105 and 120 degrees Fahrenheit.
Common Areas
: These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
(Continued on LIC809-C)
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Evelin Rios
TELEPHONE:
424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2023
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
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Document Has Been Signed on
10/16/2023 05:27 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:
CASA AMORE
FACILITY NUMBER:
197609345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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 two (2) out of two (2) staff present at the facility not having current CPR/First Aid certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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Licensee will make sure to have a staff with (CPR) training and first aid training on duty and on the premises at all times. Licensee will provide a copy of CPR/First Aid certification for both staff by POC due date.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of six (6) residents by accepting and administering medication with an altered label which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/17/2023
Plan of Correction
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Licensee will immediately contact responsible person/ primary physician / pharmacists to obtain the correct prescription dosage. A copy of prescription with dosage will be provided to LPA by POC due date.
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:
10/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2023
LIC809
(FAS) - (06/04)
Page:
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of
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Document Has Been Signed on
10/16/2023 05:27 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:
CASA AMORE
FACILITY NUMBER:
197609345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 record review, the licensee did not comply with the section cited above in two (2) out of two (2)present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/03/2023
Plan of Correction
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Licensee will schedule all staff for vendorized annual training and provide either completed certification of training or registration of future scheduled training of all staff to LPA by POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
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 one (1) out of six (6) residents did not have medical assessment provided to the facility before being admitted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/27/2023
Plan of Correction
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Licensee will request a medical assessment / physician's report and provide a completed copy to LPA by POC due date.
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:
10/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2023
LIC809
(FAS) - (06/04)
Page:
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of
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Document Has Been Signed on
10/16/2023 05:27 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:
CASA AMORE
FACILITY NUMBER:
197609345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/16/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in not providing planned activities for the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/20/2023
Plan of Correction
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Licensee will create a lisit of planned activities for residents and provide a copy to LPA by POC due date.
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
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Based on record review, the licensee did not comply with the section cited above in one (1) out of six (6) residents not having an annual medical assessment or reappraisal conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/27/2023
Plan of Correction
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Licensee will request a medical assessment conducted for resident in question and provide copy of complete medical assessment/physician's report to LPA by POC due date.
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:
10/16/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2023
LIC809
(FAS) - (06/04)
Page:
4
of
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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:
CASA AMORE
FACILITY NUMBER:
197609345
VISIT DATE:
10/16/2023
NARRATIVE
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The smoke alarms are hired wired and interconnected. A carbon monoxide detectors was observed in the hallway by the bedrooms. Administrator tested smoke and carbon detector at 11:09 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and was observed fully charged.
Surrounding Grounds
: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room and garage locked. LPA observed a second refrigerator with food in the garage.
Resident Files
: LPA conducted a file review of resident records to insure compliance of licensing forms at at approximately 12:15 p.m. Records revealed a Medical Assessment was not on file before admitting resident #2 (R2). According to administrator they had requested it from the responsible person but had yet to receive it. Records for Resident #4 (R4) revealed they have dementia and did not have a medical assessment and a reappraisal done at least annually for 2021, 2022 and 2023.
Staff Files
: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Staff records review of two (2) staff present at the facility revealed two (2) out of two (2) staff did not have current CPR and First Aid certification on file. Record review for two (2) out of two (2) staff revealed annual training was not on file.
Medications
: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for six (6) of six (6) residents revealed revealed Resident #1's (R1's) medication label was altered by someone other then the dispensing pharmacist. According to administrator medication is provided by R1's responsible person and it was already altered when provided to the facility.
At approximately 3:00 p.m. LPA interviews with residents and staff revealed facility does not have planned activities.
Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit (refer to LIC809-D). Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Evelin Rios
TELEPHONE:
424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE:
10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/16/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5