197610193-2-13-2024-31-AS-ERIS-D2EUKV-20240213143947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610193
Report Date: 02/13/2024
Date Signed: 02/13/2024 02:39:54 PM

Document Has Been Signed on 02/13/2024 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:	A HOME FOR MOM & DAD		FACILITY NUMBER:	197610193
ADMINISTRATOR:	APOLINARIO, EMMA L.		FACILITY TYPE:	740
ADDRESS:	44856 33RD STREET W		TELEPHONE:	(661) 418-0016
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Emma Apolinario		TIME COMPLETED:	02:45 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 02/13/24 at 11:30 a.m. Licensing Program Analyst (LPA) Evelin Rios conduct an unannounced annual inspection. LPA was greeted by staff #1 (S1). LPA observed hand sanitizer, and a visitor sign in log. LPA met with the administrator Emma Apolinario and Amante Apolinario. LPA explained to the administrator the purpose of the visit and an entrance interview was conducted. The facility is a two story home with a fire clearance for five (5) non-ambulatory residents and one (1) bedridden resident for a capacity of 6 residents. At approximately 11:32 a.m. LPA 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 drawer in the kitchen. Medication was observed stored in a locked kitchen cabinet. Bedrooms: There are five (5) bedrooms designated for residents' use. Two (2) of the bedrooms are currently vacant. Bedroom #1 is shared. Rooms occupied by residents were properly furnished with appropriate beddings, linens and with sufficient lighting. LPA observed half bed rails on resident's #2 (R2's) bed. LPA observed half rails on resident #3 (R3) bed. Bathrooms: There is (1) bathroom designated for residents' use. Bathroom was properly supplied and had functional fixtures. Hot water temperature was taken 1:32 p.m. and read 117.8 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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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Document Has Been Signed on 02/13/2024 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: A HOME FOR MOM & DAD	FACILITY NUMBER: 197610193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in staff #1 (S1) not being associated to the facility or having a requested transfer on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	S1 left the facility and will not return until they are associated. Administrator will associate S1 through Guardian or submit a signed Criminal Background Clearance Transfer Request, LIC 9182 with required documentation to the regional office.

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: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/13/2024 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: A HOME FOR MOM & DAD	FACILITY NUMBER: 197610193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 2 out of 2 staff not having active or current First aid and CPR which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Administrator will provide a copy of certification to LPA by POC due date.

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 R3 not having a physician's order for a half bed rail which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	Administrator will obtain the physician's order for R3's bed rail and provide a copy to LPA by POC due date.

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: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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: A HOME FOR MOM & DAD	FACILITY NUMBER: 197610193
	VISIT DATE: 02/13/2024

NARRATIVE

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The smoke alarms are interconnected. LPA observed a carbon monoxide detector in the hallway leading to the bedroom. Administrator tested smoke detectors at 11:33 a.m. and were observed to be functioning properly. The fire extinguisher is located by the kitchen observed fully charged with purchase date 08/02/23.
Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed three sheds used for storage. Door leading to the garage was locked. LPA observed a deep freezer with food in a hallway. Detergents and cleaning products are kept in the laundry room inaccessible to residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:00 p.m. LPA's record review for R2 revealed they had an order for bed rails. LPA's record review for R3, R3 did not have an order for bed rails. According to administrator R2 and R3 were on hospice at some point.
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. LPA did not observed current first aid and CPR certification for administrator or S1 who was assisting residents during today's visit. Review of S1's records revealed S1 is not associated to the facility. S1 is fingerprinted and background cleared and was at some point associated to this facility when it was going by a different name. LPA did not observe a transfer request on file. According to administrator S1 was just called in as a temp.

Medications: At 1:00 p.m. LPA and administrator reviewed medication and medication records for proper documentation. Facility keeps Medication Administration Records (MAR)

Deficiencies observed during the visit (refer to LIC809-D). 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: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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