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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610154
Report Date: 07/11/2024
Date Signed: 07/11/2024 01:52:29 PM


Document Has Been Signed on 07/11/2024 01:52 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 PRECIOUS CARE VILLAFACILITY NUMBER:
197610154
ADMINISTRATOR:DOMINGO, OLIVERFACILITY TYPE:
740
ADDRESS:8413 RHEA AVETELEPHONE:
(818) 626-9343
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Oliver Domingo- LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit to the above facility. During file review, LPA observed that Staff#1 (S1) is missing required Licensing forms from the personnel file. In addition, Resident#1 (R1), Resident #2 (R2) and Resident #3 (R3) do not have a written hospice care plan as specified CCR 87633(a)(4) prior to the initiation of hospice services. Moreover, the Licensee did not notify the Department in writing within five (5) working days of the initiation of hospice for R1, R2 and R3 as specified in CCR 86632(d)(2) and stipulated on the approved Hospice Waiver. Lastly, Licensee have not provided a written request signed by each terminally ill resident or prospective resident upon admission, or by the resident's or prospective resident’s health care surrogate decision maker to allow for his or her acceptance or retention in the facility while receiving hospice services.

Exit interview conducted, citations issued, appeal rights given and copy of this report delivered.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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 07/11/2024 01:52 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 PRECIOUS CARE VILLA
FACILITY NUMBER: 197610154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2024
Section Cited
CCR
87412(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
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Administrator will email LPA the requested documents by the POC date.
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Based on record review, the licensee did not comply with the section cited above. S1 is missing forms LIC 501 , LIC 503, LIC 508. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
07/25/2024
Section Cited
CCR87633(a)(4)

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Hospice Care of Terminally Ill Residents (a) The licensee shall... (4) A written hospice care plan ... is developed for each terminally ill resident ... by that resident’s hospice agency and agreed to by the licensee and the resident. This requirement was not met as evidenced by:
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Administrator will email hospice care plans for R1, R2, and R3 to LPA by the POC date
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Based on record review, the licensee did not comply with the section cited above in three (03) out of four (04) residents which poses a Health, Safety, or Personal rights risk to persons in care.
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/11/2024 01:52 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 PRECIOUS CARE VILLA
FACILITY NUMBER: 197610154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2024
Section Cited
CCR
87632(d)(1)

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A written request shall be signed by each terminally ill resident or prospective resident upon admission, or by the resident's or prospective resident’s health care surrogate decision maker to allow for his or her acceptance or retention in the facility while receiving hospice services.
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Administrator will email LPA written requests signed by each terminally ill resident or prospective resident’s health care surrogate decision maker to allow for his or her acceptance or retention in the facility while receiving hospice services by the POC date
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Based on record review, the licensee did not comply with the section cited above in three (03) out of four (04) residents which poses a Health, Safety, or Personal rights risk to persons in care
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Type B
07/25/2024
Section Cited
CCR87632(d)(2)

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The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
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Administrator will email LPA three (3) hospice notifications for R1, R2 and R3 by the POC date.
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Based on record review, the licensee did not comply with the section cited above in three (03) out of four (04) residents which poses a Health, Safety, or Personal rights risk to persons in care
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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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3