197610178-10-9-2023-31-AS-ERIS-CWFUM5-20231009154147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610178
Report Date: 10/09/2023
Date Signed: 10/09/2023 03:42:29 PM

Document Has Been Signed on 10/09/2023 03:42 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:	ANNIKA GRACE CARE HOME		FACILITY NUMBER:	197610178
ADMINISTRATOR:	BATUIAN, JOZAM LATAYAN		FACILITY TYPE:	740
ADDRESS:	6338 W AVENUE J11		TELEPHONE:	(818) 802-8004
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jozam Batuian		TIME COMPLETED:	03:45 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 10/09/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Jozam Batuian. LPA observed covid-19 signs at the front door and required postings were observed in the entry area. LPA Rios explained the purpose of the visit. At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Bedrooms: There were six (6) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. One (1) room is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 11:48 a.m. and read 110.6 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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

FACILITY NAME: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
	VISIT DATE: 10/09/2023

NARRATIVE

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The smoke alarms are dual carbon monoxide detectors they are hired wired and interconnected. Administrator tested smoke/carbon detectors at 12:00 p.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and the laundry room with purchase date 08/22/23.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:10 p.m.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:47 p.m.

Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for two (2) of two (2) residents revealed medication dosages were inaccurate for both residents. According to administrator medication dosage taken had been updated but he had not had a chance to update the dosage on CSDMR. LPA observed Destruction log record was missing for medication indicated discontinued on (CSMDR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2023 03:42 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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 two (2) out of two (2) residents, Centrally Stored Medication Destruction Records had inaccurate dosage and missing Destruction log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee will complete Centrally Stored Medication Destruction Record (CSMDR) for all residents to accurately match the dosage on medication bottle. Licensee will send a copy of accurate CSMDR to LPA by POC due date.

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: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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