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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609853
Report Date: 08/05/2021
Date Signed: 08/09/2021 09:13:41 AM

Document Has Been Signed on 08/09/2021 09:13 AM - 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:REESEJOY CARE HOME IIFACILITY NUMBER:
197609853
ADMINISTRATOR:RAMIREZ, ROBERTOFACILITY TYPE:
740
ADDRESS:17544 SAN JOSE STTELEPHONE:
(805) 832-8792
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 4DATE:
08/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Roberto Ramierz TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) LaQueena Lacy and Licensing Program Manager (LPM) Cassandra Harris conducted an unannounced case management visit to issue deficiencies observed while conducting a complaint visit. During the course of the investigation for complaint control # 31-AS-20210720125321.

LPA and LPM conducted a physical plant tour at 9:35am. At approxitmately 10:03am LPA and LPM requested documents relevant to the case management visit. LPA and LPM observed two(2) out of the four (4) residents files that receives hospice care, did not have a hospice care plan from the hospice agency to detail what needs and services or medication orders present for the residents.

LPA and LPM observed (2) out of ( 4) residents files that had Pro Re Nata (PRN) medications, but did not include a PRN authorization letter from their physician.

At 10:10am LPA and LPM observed staff Michelle crush multiple medications and placed them in a vanilla pudding cup to feed to resident Eunice. LPA and LPM observed medications missing from the medication bubble pack as well as expired medication. LPA and LPM observed one (1) green pill taped in a bubble pack that had all white pills for a missing day in the white pill bubble pack. Observed to be two (2) different medications.

LPA was unable to obtain licensee signature at the time of visit due to LPA having computer issues (consistency check). Copy will be emailed for a signature.

Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 809-D.

Exit interview conducted. Copy of this report and appeal rights issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
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 3
Document Has Been Signed on 08/09/2021 09:13 AM - It Cannot Be Edited


Created By: LaQueena Lacy On 08/05/2021 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REESEJOY CARE HOME II
FACILITY NUMBER: 197609853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2021
Section Cited
CCR
87465(a)(6)(d)

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A plan for incidental medical and dental care shall be developed by each facility. Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed.
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Licensee will ensure that all Physician and medication orders are followed properly and documented accordingly. Licensee will ensure staff is knowledgeable regarding all residents in care needs and service plans, and any special orders that have been issued by the physician and/or hospice care.
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Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
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Licensee will provide in-service training to all staff regarding each resident needs and service plan and proper instruction on all medications. In-service sign in sheet and completion certificate will submitted to LPA.
Type B
08/15/2021
Section Cited
CCR87633(a)(4)

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The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services. A written hospice care plan which specifies the care.
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Licensee will submit all hospice care plans for all residents that receive hospice care, to will ensure that all documentation is signed by all physicians and hospice care providers. Licensee will submit all hospice care plans for all residents receiving hospice care.
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services, and necessary medical intervention related to the terminal illness care and supervision provided by the facility is developed for each terminally ill resident and agreed to by the licensee and the resident and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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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:Naira Margaryan
LICENSING EVALUATOR NAME:LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2021 09:13 AM - It Cannot Be Edited


Created By: LaQueena Lacy On 08/05/2021 at 02:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: REESEJOY CARE HOME II
FACILITY NUMBER: 197609853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2021
Section Cited
CCR
87465(b)

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If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
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Licensee will ensure that all MARS and PRN are logged correctly and documented properly. Licensee will provide an in-service training to staff regarding each residents needs and service plans and how to properly document PRN medication. Licensee will provide PRN authorization letters signed by the physician for all residents that have PRN medications and a
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sign in sheet, and completion certficates for the in-service training to LPA.

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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:Naira Margaryan
LICENSING EVALUATOR NAME:LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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