197609923-7-26-2023-29-AS-SURA-CU4TP4-20230726145342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609923
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:55:37 PM

Document Has Been Signed on 07/26/2023 02:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BASSETT RESIDENTIAL CARE		FACILITY NUMBER:	197609923
ADMINISTRATOR:	TAVITIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	16017 BASSETT ST		TELEPHONE:	(818) 442-5702
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 5	DATE:	07/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Emma Aruitunian		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	Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct the annual inspection year Required inspection of the facility. LPA met with administrator Emma Arutiunian and explained the reason for the visit. The LPA and the administrator conducted a tour of the physical plant at approximately 10:30 a.m. There are (6) bedrooms for residents and (1) bedroom for staff use only. Smoke alarms and carbon monoxide detector were not functioning at time of the visit. The administrator stated that the smoke and carbon monoxide alarm started emitting a sound at night and that could not be resolved by staff. The administrator contacted an alarm company to resolve the issue and stated that the company was going to resolve the issue same day of the visit later in the afternoon. The LPA observed all required postings in the entry area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Fire extinguisher was fully charged and purchased in May 23, 2023. KITCHEN: The kitchen appeared clean and the appliances and fixtures functional during the time of visit, sharp objects are stored in lock box that was kept on the kitchen counter. The LPA observed box to be locked at this time. Some cleaning supplies and disinfectants were observed stored inaccessible to residents under the sink. The LPA observed a sufficient amount of perishable and a seven-day supply of non-perishable food at the facility properly stored, however the facility lacked a water supply. The administrator stated that the water will be purchased by the end of the day and pictures of the water supply will be emailed to LPA by 07/27/2023. BEDROOMS: The residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate and clean bedding and linens such as sheets, pillowcases, and blankets. Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
	VISIT DATE: 07/26/2023

NARRATIVE

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BATHROOMS: The LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in the bathroom. Residents have sufficient amounts of supplies for personal hygiene properly stored inaccessible to residents. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit.
COMMON AREAS: The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Laundry room is located right outside the hallway pass bedrooms #5 and #6. The LPA observed laundry room to be inaccessible to residents in care at this time. Cleaning supplies were stored in cabinets above washer and dryer. LPA observed cabinets to be locked at this time. There is an attached garage accessible from the outside and the laundry room. LPA observed garage to store an extra fridge and freezer for perishable foods. Extra medical supplies and furniture was also observed in the garage. SURROUNDING GROUNDS (Outdoors): Exit passageways were clear of hazards and obstructions. There was an area with proper furniture for outdoor use in the area located outside of living room to the left of the property, however the outdoor area lacked shade. The LPA informed the administrator that some form of shade (patio umbrella), must be provided for the comfort of residents and family members if they wish to meet outdoors. There are no bodies of water on the premises.
Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to isolate residents in their private bedrooms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
RECORDS: Records review began at 12:00p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:12 p.m., medications are centrally stored and locked in a cabinet in the hallway; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications; however, the dates of bottles did not match the Centrally Store Medication and destruction record as of the time of the visit. An audit of two out of two medication bottles: Quetiapine (250mg, and 500mg) did not have the correct amount of tablets left in the bottles, as prescribed. Citations were issued. Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2023 02:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BASSETT RESIDENTIAL CARE	FACILITY NUMBER: 197609923
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 two out of two smoke/carbon monixide detectors were not functioning, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/27/2023
	Plan of Correction
1 2 3 4	Adsministrator stated that the detectors will be in working condition by the end of the date of this report, and will send the department a copy of the work performed by a licensed professional.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 since two out of two centrally stored and destruction medication records were not up to date, and two out of two medication bottles the medication was not given acccording to the physician's deirections, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Administrator will update all Centrally Stored and Desrtuction Medication records to reflect when the medication was filled and started, and will email the department.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC809 (FAS) - (06/04)

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