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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320184
Report Date: 09/26/2022
Date Signed: 09/27/2022 08:53:08 AM

Document Has Been Signed on 09/27/2022 08:53 AM - 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:AVENIR MEMORY CARE WESTSIDEFACILITY NUMBER:
198320184
ADMINISTRATOR:DRINKHOUSE-QUINTA, MARISSAFACILITY TYPE:
740
ADDRESS:7501 OSAGE AVETELEPHONE:
(424) 282-0040
CITY:LOS ANGELESSTATE: CAZIP CODE:
90045
CAPACITY: 88CENSUS: 23DATE:
09/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:JUDY ARREAGATIME COMPLETED:
04:00 PM
NARRATIVE
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On 9/26/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency observed during an unrelated visit. LPA met with Cari Ramos and Jacqueline Vu, The Business Office Manager shortly after and LPA explained the purpose of today's visit. Vu introduced LPA to the Director of Health Services, Judy Arreaga, who assisted LPA with the visit.

LPA observed Staff #2 who is not appropriately skilled professional administered medication through injection to Resident #6.

Deficiencies noted and citations issued during today's inspection visit per California Code of Regulations, Title 22, Division 6, Chapter 8 which are being cited on the the attached LIC809D.

Exit interview conducted, Appeal Rights discussed and copy of the report and appeal rights were given to Department of Health Services, Judy Arreaga.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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 2
Document Has Been Signed on 09/27/2022 08:53 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/26/2022 at 02:35 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: AVENIR MEMORY CARE WESTSIDE
FACILITY NUMBER: 198320184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
Section Cited
CCR
87628(a)

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87628 Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.
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Administrator shall ensure that only appropriately skilled professional administer medication through injection to residents in care. Administrator shall read Section 87628 of Title 22 and self-certify understanding of the regulation and shall comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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LPA observed R1 and R6 sitting in the dining room on the second floor while S2, who is not appropriately skilled professional to administer medication through injection, injected an insulin to R6. LPA confirmed that S2 injects insulin to R6 three times a day. This poses an immediate health, safety, and/or personal rights risk to residents in care.
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Type A
09/27/2022
Section Cited
CCR87405(d)(4)

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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (4) When applicable, the ability to direct the work of others.
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Administrator shall ensure only appropriately skilled professional administer medication through injection to residents in care. Administrator shall appropriately direct the work of others. Administrator shall read this section of Title 22 and shall self-certify understanding of the regulation and shall comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov.
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The administrator failed to ensure only appropriately skilled professional administer medication through injection to residents in care. LPA observed S2 injecting R6 with insulin and S2 confirmed she injects R2 with insulin three times daily. This poses an immediate health, safety and/or personal rights risk to residents in care.
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022


LIC809 (FAS) - (06/04)
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