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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202967
Report Date: 10/20/2021
Date Signed: 10/30/2021 02:56:24 PM

Document Has Been Signed on 10/30/2021 02:56 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ANAND CARE CENTER IIIFACILITY NUMBER:
198202967
ADMINISTRATOR:MEHUL PATELFACILITY TYPE:
735
ADDRESS:11143 SOUTH PRARIE AVETELEPHONE:
3104191225
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 20CENSUS: 15DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Patel MehulTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the facility and left a voicemail message. LPA Bunker received a return call from Administrator Pattel Mehul we spoke via telephone and LPA Bunker conduct a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection.

LPA Bunker met with staff Patel Mehul and explained the purpose of today's visit. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA verified that the facility has an approved Mitigation Plan Report. Mr. Mehul stated all staff and all residents except one (1) are fully vaccinated.

The above facility is a two-story converted hotel building located in a business area which consists of: 18 bedrooms, 18 bathrooms, kitchen, dining room, laundry room, storage room, 7 detached carport, shaded area, indoor/outdoor activity areas. During the visit
Mr. Patel and LPA Bunker toured the facility and observe the following bedrooms and bathrooms:

Continued LIC809-C page #2
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ANAND CARE CENTER III
FACILITY NUMBER: 198202967
VISIT DATE: 10/20/2021
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Continued LIC809-C page #2

Resident bedrooms contain the required furniture, bed, one chair, nightstand, adequate lighting, a closet, and chest of drawer's space. There was ample space to accommodate each resident comfortably.

Documents were posted as mandated on the wall in the office and on the bulletin board in the dining area. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The resident's bedrooms were inspected for safety, privacy, and comfort. The bathrooms are operational. First aid kit is fully stocked with manual, hot water temperature 117.4 degrees Fahrenheit, adequate lighting, working telephone, fire alarm pull station, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the kitchen cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, no firearms on the premises, client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, all outdoor and indoor passageways are free of obstruction, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

Mr. Patel states staff was given training on dependent adult and elder abuse reporting.

The following deficiencies of the California Code of Regulations, Title 2, Division 6, Chapters 1 and 6 are cited on attached LIC809-D. Appeal Rights issued and discussed.



Exit interview conducted.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/30/2021 02:56 PM - It Cannot Be Edited


Created By: Pamela Bunker On 10/20/2021 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANAND CARE CENTER III
FACILITY NUMBER: 198202967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087 (a) Buildings and Grounds: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The carpet in resident's rooms #5, 10. 15, 16, 19 have rips, torn edges, wrinkles, dust, dark black and brown, spots, and stains. Which posed a potential health, safety, or personal rights risk to clients in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee needs to ensure the resident's rooms carpet in rooms #5, 10, 15, 16, and 19 is clean and in good repair at all times. The carpet needs to be removed and replaced.
By the POC due date of 11/22/2021
Section Cited
Deficient Practice Statement
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80087 (a) Buildings and Grounds: The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The bathrooms in #5, 10, 15, 16, and 19, floors, walls, ceilings, sinks, toilets and showers have mildew, dark brown and black spots, and stains. The tile near the shower is cracked. Room #15 toilet seat is broken. Which posed a potential health, safety, or personal rights risk to clients in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee needs to ensure the resident's bathrooms #5, 10, 15, 16, and 19 are clean and in good repair at all times. Licensee needs to clean the bathrooms floors, walls, ceilings, sinks, toilets, and showers and also, repaint the bathrooms and replace crack and broken tile.
By the POC due date 11/22/2021
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Pamela Bunker
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/30/2021 02:56 PM - It Cannot Be Edited


Created By: Pamela Bunker On 10/20/2021 at 01:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ANAND CARE CENTER III
FACILITY NUMBER: 198202967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087 (a) Buildings and Grounds: The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well-being of clients, employees, and visitors. LPA Bunker observed the kitchen entrance doorway's wood framing is open and exposed and needs to be repaired. Which posed a potential health, safety, or personal rights risk to clients in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee needs to ensure the kitchen entrance doorway is repaired.
By the POC due date 11/22/2021
Section Cited
Deficient Practice Statement
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85088 (c) (4) Fixtures, Furniture, Equipment and Supplies: Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and washcloths. Room #15 twin bed lining is uncleaned, has black and brown dark spots and stains. Which posed a potential health, safety, or personal rights risk to clients in care.
POC Due Date: 11/01/2021
Plan of Correction
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Licensee needs to ensure the resident's bedding in room #15 is clean or replaced and in good repair at all times.
By the POC due date 11/22/2021
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Pamela Bunker
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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