197610031-5-30-2023-29-AS-SURA-CSBTSX-20230530145954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610031
Report Date: 05/30/2023
Date Signed: 05/30/2023 03:01:03 PM

Document Has Been Signed on 05/30/2023 03:01 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:	CARMEL OAKS ASSISTED LIVING		FACILITY NUMBER:	197610031
ADMINISTRATOR:	NIRVANA GHAEMI		FACILITY TYPE:	740
ADDRESS:	4607 LENNOX AVE		TELEPHONE:	(818) 277-1948
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY:	6	CENSUS: 6	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Nirvana Ghaemi		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPAs) Sandra Urena and Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:04 a.m. The LPAs met with Administrator Nirvana Ghaemi, and explained the reason for the visit.

The LPAs, and the Administrator toured the physical plant areas at 10:20 a.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food and non-perishable food. At 11:50 a.m., the LPAs and the Administrator observed the kitchen knives to be stored in a locked cabinet drawer to the left side of the stove

BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three bedrooms for resident use; room#3 is vacant, room #4 and room #5 are currently occupied as staff rooms.

RESTROOMS: Residents’ restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Proper hand washing signs were displayed, and paper towels were available.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition.

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: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
	VISIT DATE: 05/30/2023

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The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices. The LPAs and the administrator observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is detached from the home.

RECORDS: Residents’ records review began at 11:36 a.m., 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 1:25 p.m. Medications are centrally stored and locked in a cabinet in staff’s room #4. Medications were labeled and checked for expiration dates. Medications are properly documented on the Centrally Stored Medication & Destruction Record (LIC 622), however the LIC622 for each resident, was not updated to reflect the current start of the medication. Three residents’ medications were audited for reliability of assistance with medications. The audit revealed that six out of six prescription medication bottles contained more pills than the actual number stated in the prescription bottle. Per the Administrator, they believe that the staff is transferring pills from a current prescription bottle to a newly received prescription bottle, consequently, the number of pills in the bottles audited did not reflect the amount of pills per the new filled prescription.

INFECTION CONTROL: 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 designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPAs obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, Staff schedule.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2023 03:01 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: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 six out of six prescription medication bottles had incorrect number of pills, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	Licensee agrees to contract with a credentialed entity to conduct staff training on handling of the medication, medication bottles, and send a copy of the training materials, sign in sheet, and the name, address and phone number of the credential entity. Licensee will email proof of tratining to LPA .

Section Cited

Incidental Medical and Dental Care Services


	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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/30/2023 03:01 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: CARMEL OAKS ASSISTED LIVING	FACILITY NUMBER: 197610031
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above as three first aid items were not available during the audit( first aid manual, scissors, twizzers, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Licensee agrees to place missing items in the first aid kit by 06/02/2023, and send pictures to LPA via email.

Section Cited

Incidental Medical and Dental Care Services


	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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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