197801028-6-7-2024-28-AS-EZAA-D5ZUR8-20240607154818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801028
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:49:32 PM

Document Has Been Signed on 06/07/2024 03:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GOLDEN APRICOT MANOR		FACILITY NUMBER:	197801028
ADMINISTRATOR:	SERBAN, NICULINA		FACILITY TYPE:	740
ADDRESS:	16875 SAUSALITO DR.		TELEPHONE:	(562) 694-5282
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	10	CENSUS: 6	DATE:	06/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Verna Chisholm - Caregiver		TIME COMPLETED:	03:58 PM

NARRATIVE

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Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Verna Chisholm, caregiver for the home, and was granted entrance to the facility. Administrator and Joanna De Castro arrived shortly thereafter. There are six (6) residents currently living in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents, and is also approved for a hospice waiver for three (3) residents, however there are two (2) residents residing in the home that are identified as bedridden in their physician’s report which violates their fire clearance. The facility consists of a living room, a dining room, ten (10) resident rooms, multiple residents bathrooms which LPA measured and most reached the required range of 105 – 120 degrees Fahrenheit except for the bathroom in bedroom #3 which does not have operational hot water. Additionally, there was observable mold found on the ceiling of the residents’ shower room. The facility also has a kitchen, a dining room, a living room, a backyard area which contains a shed for tools, and a detached garage that contains the facility’s laundry machines and emergency food supplies, along with the facility’s chemicals and cleaning supplies. Knives and sharp objects are kept locked in the a locked cabinet in the kitchen. The facility was observed to be in good repair.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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 06/07/2024 03:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 residents, because 2 residents were identified as bedridden based on their physician's reports, and the license does not have an approval for any bedridden residents on the fire clearance, which poses an immediate safety or personal rights risk to persons in care.
	POC Due Date: 06/08/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that the facility is operating within the limits of the license at all times. Administrator is to notify the local fire department of the bedridden residents, and submit a request to CCLD including an LIC200 along with an updated facility sketch that identifies the bedridden room(s), by the 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/07/2024 03:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents, because there was observable mold on the ceiling of the resident's shower, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that the facility shall be clean, sanitary, and in good repair at all times. Administrator is to clear the mold on the shower's ceiling and email LPA photograph proof that it has been removed by the POC due date.

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 6 residents, as one of the resident's hot water was entirely cut off in their room's bathroom, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that all faucets used by residents for personal care shall deliver hot water at all times. Administrator is to restore the hot water in resident bathroom #3 and email LPA a water temperature log for 7 days showing that the water is meeting the required range by the 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/07/2024 03:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff, because 4 staff files reviewed did not document that annual retraining had been conducted in the past 12 month related to dementia care, hospice care, postural supports, and restricted health conditions, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that documented retraining on dmentia care, hospice care, postural supports, and restricted health conditions is kept on file at the facility at all times. Administrator is to email LPA the facility's plan on how they will conduct annual retrainings on the required topics by the POC due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 6 residents, because there are 3 residents that have a dementia diagnosis and have not had their physician's report or reappraisal updated within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that all residents that have a Dementia diagnosis have their physician's reports and appraisals updated every 12 months. Administrator to email LPA the facility's plan on how they will ensure that they will update the resident's physician's report and appraisals when required to do so, and also work on submitting LPA the identified residents updated Physician's Reports and appraisals by the 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
	VISIT DATE: 06/07/2024

NARRATIVE

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguisher located in the kitchen of the facility. There were no sharp objects that were left accessible to residents.
· One (1) of the restrooms toured did not reach the required hot water temperature reading of 105 - 120 degrees Fahrenheit.

Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, and is also approved for a hospice waiver for three (3) residents

· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Twenty-two (22) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, certifications, and 1st Aid/CPR training.
· Administrator’s certificate expires on 3/21/2025.

Resident Rights/Information:

· Physician orders were reviewed for six (6) resident files.

· Medications were also reviewed for six (6) residents.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
	VISIT DATE: 06/07/2024

NARRATIVE

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Resident Records/Incident Reports:

· Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

· Three (3) residents diagnosed with Dementia did not have their physician’s report or appraisal updated within the past twelve (12) months as required by Title 22 regulations.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· An emergency and disaster drill was last conducted on 5/30/2024.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GOLDEN APRICOT MANOR	FACILITY NUMBER: 197801028
	VISIT DATE: 06/07/2024

NARRATIVE

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Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· The facility has a non-ambulatory fire clearance for each room that will be used to accommodate residents with a dementia diagnosis.

· There was no documentation on file for four (4) out of five (5) staff members that they have conducted their required annual retraining related to Dementia Care, Hospice Care, Postural Supports, and Restricted Health Conditions.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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