197609821-10-10-2023-31-AS-ERIS-CWGU2N-20231010151212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609821
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:12:20 PM

Document Has Been Signed on 10/10/2023 03:12 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:	A HOME FOR YOU		FACILITY NUMBER:	197609821
ADMINISTRATOR:	NEPOMUCENO, MERLITA		FACILITY TYPE:	740
ADDRESS:	43845 GENERATION AVE		TELEPHONE:	(818) 357-8667
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Merlita Nepomuceno		TIME COMPLETED:	03:15 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	On 10/10/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA observed covid-19 signs at the front door and required postings were observed on a wall by the living area. LPA Rios explained the purpose of the visit to the administrator. At 10:20 a.m. LPA and administrator Merlita 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. Cleaning products were stored in a locked cabinet under the kitchen sink. Medication stored in a locked kitchen cabinet. Bedrooms: There are four (4) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. Bedroom #3 is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. LPA observed a full bed rail on resident #1's (R1's) bed. Bathrooms: There are two (2) bathrooms 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 10:40 a.m. and read between 105 and 120 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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: A HOME FOR YOU	FACILITY NUMBER: 197609821
	VISIT DATE: 10/10/2023

NARRATIVE

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The smoke alarms are battery operated and interconnected. LPA observed a carbon monoxide detector by the living area and kitchen. Staff #1 (S1) tested smoke and carbon detectors at 10:43 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 07/14/23.

Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. A staff room that is maintained locked leads to the laundry room which leads to the garage. LPA observed a deep freezer with food. Detergents and cleaning products are kept in the laundry room locked.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:08 p.m. LPA's record review for resident #1 (R1), R1 had an order for a full bed rail but R1 is not terminally ill according to R1's physician's report. According to Licensee Nathan, R1 is receiving Hospice service for palliative care.

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 at 12:35 p.m.

Medications: At 1:43 p.m. LPA and administrator reviewed medication and medication records for proper documentation.

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 03:12 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: A HOME FOR YOU	FACILITY NUMBER: 197609821
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87608(a)(5)(B)

(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. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of four (4) residents, by having full bed rails on resident #1's (R1) bed who is not terminally ill which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator will remove full bed rails and send picture 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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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