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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600265
Report Date: 03/19/2024
Date Signed: 03/19/2024 04:20:45 PM

Document Has Been Signed on 03/19/2024 04:20 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:ERNIE'S PLACEFACILITY NUMBER:
198600265
ADMINISTRATOR:GARCIA, NOEYFACILITY TYPE:
735
ADDRESS:630 N. NICHOLSONTELEPHONE:
(626) 280-7205
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 6CENSUS: 5DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Karen Gazon, Co-AdministratorTIME COMPLETED:
04:24 PM
NARRATIVE
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Licensing program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate complaint allegations. LPA met with Co-Administrator Karen Gazon and discussed the purpose of the visit.

During the visit LPA reviewed and obtained staff and resident roster, MAR for C1 for months of February and partial month of March 2024. Reviewed medication for C1, obtained last dental appointment documentation for C1, DC order for C1, PRN authorization letters for all 5 clients (C#1-C#5) interviewed Five staff (S#1-S#5) and two residents (R#1-R#2) Notice of change in coverage for C1 medication.

During review of the medications, LPA observed three PRN medications(Pepto Bismo, Acetaminophen, and Triple antibiotic ointment) with generic label that read "HOUSE SUPPLY. USE AS DIRECTED" and nothing else. Client name, dose and label was missing from PRN as well as separate PRNs for each client.

Deficiency cited on 809D

Exit interview conducted, copy of report, 809D, and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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 03/19/2024 04:20 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/19/2024 at 03:46 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ERNIE'S PLACE
FACILITY NUMBER: 198600265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
80075(b)(7)

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80075(b)(7) Health Related Services. For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication.

This requirement is not met as evidenced by:
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Administrator will obtain and place labels on the PRN medications and make sure that each client has their own separate PRN with name of client, dose and MD orders that match the label by POC date and send proof to LPA.
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 LPA observed three PRN medications(Pepto Bismo, Acetaminophen, and Triple antibiotic ointment) with generic label that read "HOUSE SUPPLY. USE AS DIRECTED" and nothing else. Client(s) name, dose and label was missing for the PRN.
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024


LIC809 (FAS) - (06/04)
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