Community Care Licensing

SUPERVISOR'S NAME: Fernando Fierros TELEPHONE: (323) 981-3981 LICENSING EVALUATOR NAME: Valeria Maldonado TELEPHONE: 323-981-3342 LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023

Document Has Been Signed on 09/29/2023 11:47 AM - It Cannot Be Edited

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Type A

Section Cited

CCR

87208(c)

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). 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 obtaining approval of a dementia care plan in their plan of operations, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan in writing to LPA, via email by the POC due date, of when an updated Plan of Operations for approval of Dementia Care Plan will be submitted to Centralized Applications Bureau.

Type A

Section Cited

CCR

87705(j)

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 auditory devices not installed at entrances and exits, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licensee will purchase and install aditory devices at all entrances and exits of the facility and provide receipt of purchase and pictures of installed devices to LPA, via email, by POC due date.

SUPERVISOR'S NAME: Fernando Fierros TELEPHONE: (323) 981-3981 LICENSING EVALUATOR NAME: Valeria Maldonado TELEPHONE: 323-981-3342 LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023

Document Has Been Signed on 09/29/2023 11:47 AM - It Cannot Be Edited

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Type B

Section Cited

CCR

87470(c)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. 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 an Infection Control Plan submitted and approved to licensing, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee provided a copy of the infection control plan during the visit on 9/29/23. This deficiency is cleared.

Type B

Section Cited

CCR

87303(a)

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 broken parts of roof boards above the exit from the living room to the patio and outide the pantry door, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Licensee will make reparations needed to the roof boards and submit proof of work started/completed to LPA via email by the POC due date.

SUPERVISOR'S NAME: Fernando Fierros TELEPHONE: (323) 981-3981 LICENSING EVALUATOR NAME: Valeria Maldonado TELEPHONE: 323-981-3342 LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023

Document Has Been Signed on 09/29/2023 11:47 AM - It Cannot Be Edited

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Type B

Section Cited

CCR

87705(k)(9)

87705 Care of Persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (9) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. 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 admitting and retaining a resident with a primary diagnosis of a mental disorder unrelated to dementia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/20/2023
	Plan of Correction
1 2 3 4	Licensee will have R4 reassessed by a physician to determine any changes, otherwise will find placement of the resident. Update Physician's Report and Appraisal will be submitted to LPA via email by the POC due date.

Type B

Section Cited

CCR

87208(a)(7)(A)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions, of the following: (A)Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e) 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 changing the room occupancy of resident rooms and not providing licensing with a request for approval of change, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee will submit an updated facility sketch to LPA via email by POC due date to reflect changes of the physical plant/resident room use.

SUPERVISOR'S NAME: Fernando Fierros TELEPHONE: (323) 981-3981 LICENSING EVALUATOR NAME: Valeria Maldonado TELEPHONE: 323-981-3342 LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023

Document Has Been Signed on 09/29/2023 11:47 AM - It Cannot Be Edited

FACILITY NAME: HOME OF PERPETUAL CARE	FACILITY NUMBER: 197803655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Type B

Section Cited

CCR

87468.1

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 locking a resident's food in a caibinet to keep them from eating too much, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Staff unlocked the cabinet immediately and Licensee will keep cabinet unlocked to allow residents access to food, as they please.

Type B

Section Cited

CCR

87468.2(a)(1)

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. 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 installing surveillance cameras in common areas of the facility without an updated plan of operations, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee removed the surveillance cameras during the visit and informed LPA will submit an updated Plan of Operations in the future for security cameras.

SUPERVISOR'S NAME: Fernando Fierros TELEPHONE: (323) 981-3981 LICENSING EVALUATOR NAME: Valeria Maldonado TELEPHONE: 323-981-3342 LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023