198204374-10-28-2023-28-AS-THEA-CX2SAA-20231028134202

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204374
Report Date: 10/28/2023
Date Signed: 10/28/2023 01:42:17 PM

Document Has Been Signed on 10/28/2023 01:42 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:	SIMLA VILLAS INC.		FACILITY NUMBER:	198204374
ADMINISTRATOR:	SIMLA MEHTA		FACILITY TYPE:	740
ADDRESS:	16623 ARDMORE AVENUE		TELEPHONE:	(562) 804-3603
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	15	CENSUS: 12	DATE:	10/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Jennifer Bobadilla - Administrator		TIME COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Jennifer Bobadilla (Administrator/Caregiver) and Simla Mehta (Administrator/Licensee) and explained the purpose of today’s visit. The facility is licensed to serve 15 residents age 60 and above. 11 may be non-ambulatory and 4 bedridden. Facility is approved for 4 hospice residents (currently only 1 resident is on hospice).

The facility is located in Bellflower, CA. A tour of the facility includes: 9 bedrooms, 1 staff bedroom, 2 full bathrooms, 1 ½ bathroom, 1 staff bathroom, living room, dining room, kitchen, office area, laundry room, back yard with shaded area, detached garage and a detached shed.

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 medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and an Infection Control Plan.

Operational Requirements: The facility maintains a plan of operation and has the required liability insurance on file.
Physical Plant & Environment Safety: Smoke detectors and carbon monoxide detectors are operable and in compliance. Bathrooms are clean and operational. All residents’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available to the residents. The hot water temperature was tested in two resident bathrooms and measured between 113.3-114.2 degrees F which is within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 7/10/2023. The fire extinguishers were observed and is fully charged. Facility has telephone service on premises. There is a sprinkler system approved by the fire marshal throughout the facility. During todays visit LPA observed the opening to crawl space was not covered in two separate locations, details will be cited on 809D page.
(Continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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 10/28/2023 01:42 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: SIMLA VILLAS INC.	FACILITY NUMBER: 198204374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(2)

Incidental Medical and Dental Care Services

(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: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. 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 as 1 out of 5 clients medications did not match what facility had on medication record and 2 residents did not have an updated medication list on file during visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	Administrator to update each resident file with most current medication list and conduct an in-house training for staff that administer medication and provide a copy of the training log to LPA by 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: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/28/2023 01:42 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: SIMLA VILLAS INC.	FACILITY NUMBER: 198204374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

807303(a)

807303(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 as during physical plant tour LPA observed crawl space entrance in two locations to be uncovered, side of building did not have covering and LPA observed a cat jumb into opening, in area behind kitchen crawl space also was open with covering not properly placed, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	Licensee to place propper fittings/coverings on both crawl space areas that were exposed and submit photos of corrections to LPA via email by 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: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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: SIMLA VILLAS INC.	FACILITY NUMBER: 198204374
	VISIT DATE: 10/28/2023

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Staffing: There appears to be sufficient staffing at all times in the facility with at least one CPR trained employee on the premises at all times. Administrator Simla Mehta certificate expires 11/13/2023.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in a locked cabinet within the office area. During todays visit LPA observed 5 staff files with no issues.
Resident Records-Incident Reports: Resident files are kept in a secure location within the staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA observed 5 resident files during todays visit with no issues.
Resident Rights-Information: Complaint, Personal Rights and Ombudsman posters were observed in dining area. Residents are provided with telephone at the facility.
Planned Activities: There is an activity schedule posted in the dining area. There are board games, books and daily newspaper readily available for residents.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: All medications for residents are kept locked and inaccessible to other residents. Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. During the visit today, LPA reviewed 5 residents medications 1 out of the 5 residents had a medication that did not match what is listed on the doctors medication list, details will be cited on the 809D page.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Need: There is currently 1 resident who is on hospice and has a complete hospice care plan maintained at the facility.

LPA conducted 3 staff interviews and 2 client interviews during today’s visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on 809D. Exit interview was held and a copy of the report was provided Administrator Jennifer Bobadilla.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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