197801049-6-2-2023-28-AS-ALOZ-CSEUSK-20230602155029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801049
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:50:43 PM

Document Has Been Signed on 06/02/2023 03:50 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:	LOVING CARE HOME		FACILITY NUMBER:	197801049
ADMINISTRATOR:	MANAHAN, TEODORA		FACILITY TYPE:	740
ADDRESS:	735 E. HANKS ST		TELEPHONE:	(626) 969-2411
CITY:	AZUSA	STATE: CA	ZIP CODE:	91702
CAPACITY:	6	CENSUS: 4	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Maria Ocampo. DSP		TIME COMPLETED:	04:03 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	Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Staff Maria Angelica Ocampo DSP who allowed entry. Administrator Teodora Manohan was contacted via mobile phone and LAP discussed purpose for the visit. Administrator gave Maria authority to assist with visit. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for six ambulatory residents of which 4 may be non-ambulatory. There is a hospice waiver approved for 1 resident. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies but did not have an Infection Control Plan at the facility during the visit. Operational Requirements: The facility has plan to accept or retain clients with dementia. There are currently 0 bedridden residents and 4 non ambulatory resident residing at the facility. The facility did not have proof of enough liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: There are 4 resident bedrooms, 1 bedroom is shared. ! staff room with a bathroom 1 bathroom, living room, dining room, kitchen, and an attached garage. Facility has operable smoke and carbon monoxide detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathroom and kitchen were measured between 111.7 – 113.1 degrees F which is between the required range of 105-120 degrees. Staffing: There appears to be sufficient staffing at the facility. The administrator’s Teodora Manohan certificate expires 12/25/2023. Staff employed are all over the age of 18. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and no evidence of on-going training, Documents for staff indicate last training was in 2013.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 6

Document Has Been Signed on 06/02/2023 03:50 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: LOVING CARE HOME	FACILITY NUMBER: 197801049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 [one count, as facility did not have proof of liability insurance at the time of visit. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Administrator will provide proof of current liability insurance to LPA by POC date.

Type B

Section Cited

CCR

87468(c)(2)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: 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. Resident rights were not posted at the time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Administrator will post residents rights at the facility and send proof to LPA by POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 06/02/2023 03:50 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: LOVING CARE HOME	FACILITY NUMBER: 197801049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all the following 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 LIC 610D and emergency disaster plan reviewed was not the currently updated safety or personal rights risk to persons in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Administrator will update LIC610D AND sent proof to LPA by POC date.

Type B

Section Cited

HSC

1569.69(a)(2)

Employees assisting residents with self-administration of medication; training requirements Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview record review, the licensee did not comply with the section cited above. No staff had proof ov current traning on file during visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Administrator will provide required training to all staff and submit signed roster of training to LPA by POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 06/02/2023 03:50 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: LOVING CARE HOME	FACILITY NUMBER: 197801049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by 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. LPA observed medications in kitchen refrigerator including morphine which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Staff removed all medications from kitchen refrigerator and moved it to garage refrigerator during visit. Administrator will purchased lock box large enough to hold all refrigerated medications and/or make it inaccessible to residents.

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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/02/2023 03:50 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: LOVING CARE HOME	FACILITY NUMBER: 197801049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(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 Record review the licensee failed to obtain PRN Authorization Letters from the prescribing physicians residents PRN medications. This poses a potential Health risk to residents in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	Administrator will obtain PRN authorization letters for all residents and send proof to LPA by POC 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: LOVING CARE HOME	FACILITY NUMBER: 197801049
	VISIT DATE: 06/02/2023

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
26
27
28
29
30
31
32

Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. However, they were not up to date.
Resident Rights-Information: The Complaint poster is posted by the main entry. Visiting hours are posted. Resident rights were not posted during time of visit.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are not sufficient supplies and equipment to meet resident's physical capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination.
Incidental Medical & Dental: The medications are centrally stored and in their original containers. During the visit today, LPA review medications for 4 residents. LPA did not observe PRN authorization letters for 4 residents during visit. LPA observed some medications stored in refrigerator and accessible to residents. Medication is being administered according to doctor’s orders.
Disaster Preparedness: The facility does not have a current Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff did not received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are not posted on the doors of residents using oxygen.

During the visit today, LPA observed deficiencies and are indicated on the LIC809D.

Deficiency sited (See 809D) An exit interview was held. A copy of this report, LIC809D, and appeal rights were given to Staff Maria A. Ocampo.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6