197610178-9-23-2024-31-AS-ERIS-D9DTE9-20240923143934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610178
Report Date: 09/23/2024
Date Signed: 09/23/2024 02:39:42 PM

Document Has Been Signed on 09/23/2024 02:39 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: 3	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Jozam Batuian		TIME COMPLETED:	03:00 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 09/23/24 Licensing Program Analysts (LPAs) Angelica Segovia and Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs were greeted by the Administrator Jozam Batuian. LPA observed required postings along the entry walls. LPA explained the purpose of the visit. This is a single story home with six (6) bedrooms and two (2) and a half bathrooms. The facility has an approved fire clearance for five (5) non ambulatory and one (1) bedridden resident with a total capacity of six (6) and hospice wavier for 6. At 11:35 a.m. LPAs and administrator Jozam conducted a physical plant tour and 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 under the sink. Cleaning solutions and poisons where also locked in the cabinet under the sink. One (1) fire extinguisher was in the kitchen fully charged. Bedrooms: There were six (6) bedrooms of which three (3) are currently designated for residents' use. Three of the bedrooms are currently occupied. Bedrooms 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 and was at a comfortable temperature. . (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: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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 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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
	VISIT DATE: 09/23/2024

NARRATIVE

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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.

The smoke alarms are dual carbon monoxide detectors and are hard wired and interconnected. Administrator tested smoke/carbon detectors at 12:05 p.m. and were observed to be functioning properly.

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 and Staff Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:15 p.m. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:46 p.m.

Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for three (3) of three (3) residents revealed PRN (as needed) medications were not documented in three (3) of three (3) resident records as being given when they were. Review of three (3) residents' physician's reports revealed residents are unable to determine their own need for a prescription or nonprescription PRN medication, and are unable to communicate their symptoms clearly. According to the administrator they did not document every time an as needed medication was provided.

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: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2024 02:47 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/23/2024 02:44 PM

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: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(d)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Duplicate created in error.
	POC Due Date: 09/23/2024
	Plan of Correction
1 2 3 4	Duplicate Created IN ERROR

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: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/23/2024 02:39 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: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(d)(1-3)

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in three (3) out of three (3) residents who are unable to determine their own need for a prescription or nonprescription PRN medication, and are unable to communicate their symptoms clearly did not have documented records of the medication provided to them which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	The licensee shall review regulation 87465(d)(1-3) and submit a written memo of understanding to CCL by POC due date 9/24/24.

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: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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