197609899-12-20-2022-31-AS-ERIS-CMATM3-20221220135028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609899
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:50:45 PM

Document Has Been Signed on 12/20/2022 01:50 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:	ARCADY VILLA		FACILITY NUMBER:	197609899
ADMINISTRATOR:	CAJAYON, JOJO		FACILITY TYPE:	740
ADDRESS:	44334 LIVELY AVE		TELEPHONE:	(818) 913-2188
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Joselito Bishasa		TIME COMPLETED:	02:00 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 12/20/2022 at 9:47 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff #1 (S1) who was wearing a mask and granted access. S1 took LPAs temperature and asked LPA to sign in. S1 called another staff Joselito Bishasa to continue assisting LPA. LPA asked Joselito to call administrator JoJo Cajayon. Jojo called Joselito and LPA explained the reason for the visit and asked if he would be joining us. Jojo was an hour away and designated Joselito to sign today's report. The inspection tool was used to complete the visit. At 10:06 a.m. LPA began a physical plant tour of the facility and the following was observed: Infection Control: LPA observed appropriate infection control signs posted in front of the door. Upon entry three out of three staff were wearing masks. LPA observed appropriate signs along the entry and hand washing signs in two out of two bathrooms. Trash cans with tight fitting lids were observed in the kitchen, bathrooms and resident rooms. Joselito states the facility has enough PPE for 30 days. Dining / Living Area: The dining and living area were well lit, clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area is not in use. In the hallway by the dining area LPA observed the thermostat at a comfortable temperature of 76°F. The fire extinguisher was observed by the dining table and was last serviced on 04/29/2022. Dining table was clean and clear clutter. Furniture appeared to be clean and in good repair. Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Cleaning solutions are locked under the sink. Knives are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable and 7-day non-perishable supply of food.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARCADY VILLA	FACILITY NUMBER: 197609899
	VISIT DATE: 12/20/2022

NARRATIVE

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Bedrooms: There are six (6) bedrooms designated for resident use. One (1) out of the six (6) rooms is being occupied by staff labeled 2. All resident rooms are furnished with required lighting, dresser, chair, bed, and linens. At 10:23 a.m. LPA observed a large chair with linings on it obstructing an exit door in a resident room labeled 3. LPA asked Joselito about the chair obstructing the exit door. Joselito removed the chair from the bedroom immediately. LPA observed full length bed rails in resident's bedroom labeled 1, 3 and 5 and half bed rails in resident bedrooms labeled 4 and 6. LPA asked Joselito if any resident was in hospice care and if they had doctor orders for the bed rails. Joseilto was not sure if they had orders in resident files. Joselito called the administrator Jojo and the administrator confirmed no resident was on hospice and he would have to look at resident files to check if residents had bed rail orders. LPA advised administrator they would be reviewing resident files.

LPA observed smoke alarms through out the facility that are interconnected and dual carbon monoxide. At 10:26 a.m. all smoke alarms were tested and functioned properly.

Bathrooms: There are two (2) bathrooms designated for resident use. Both bathrooms are accessible to residents by the halllway. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 10:28 a.m. water temperature in two out of the two bathrooms was tested at 119.7 degrees Fahrenheit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating for residents with no shade. LPA observed one shed in the backyard. Shed is being used for storage.

Medications/ Resident file: LPA observed, resident medications locked in a small kitchen refrigerator and looked in a hallway cabinet inaccessible to residents. At 11:30 am LPA reviewed five out of five resident files. LPA observed half bed rail orders for one out of five resident files.

Deficiencies cited (refer to 809D). Exit interview conducted. Appeal rights provided. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/20/2022 01:50 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: ARCADY VILLA	FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608(a)(3)Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on 12/20/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 1 resident without a written order from the physician which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Licensee/administrator will tour rooms for all residents and identify those who are utilizing bed rails. Licensee/Administrator will contact the physicians and obtain order for postural support for those identified as not having one. Administrator will submit the names of the residents room numbers and dates the orders were obtained as POC.

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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/20/2022 01:50 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: ARCADY VILLA	FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

87608(a)(5)(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 12/20/2022 Annual Visit observation and record review the licensee did not comply with the section cited above in 3 out of 3 residents by utilizing full bed rails for non-hospice residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2022
	Plan of Correction
1 2 3 4	Licensee/administrator will tour rooms and identify those who are utilizing full bed rails. Licensee/Administrator will remove the full bed rails of non-hospice residents. Licensee/Administrator will send a picture of bed with removed full bed rails to LPA by POC date 12/22/2022.

Type A

Section Cited

CCR

87307(d)(6)

87307(d) The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one resident bedroom by having a large chair obstructing an indoor passageway exit door which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2022
	Plan of Correction
1 2 3 4	Staff removed the chair immediately. Licensee/Administrator will submit to LPA a statement of understanding for the regulation mentioned above by POC date 12/22/2022.

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: 12/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4