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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601665
Report Date: 08/15/2024
Date Signed: 08/16/2024 04:07:05 PM

Document Has Been Signed on 08/16/2024 04:07 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELEGANT CARE INC.FACILITY NUMBER:
198601665
ADMINISTRATOR/
DIRECTOR:		JEWEL REESEFACILITY TYPE:
740
ADDRESS:834 E. 74TH ST.TELEPHONE:
(323) 821-1601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 5DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ford Hunt, StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to S1 (Staff #1),and was granted entrance into the facility. S1 assisted with the tour of the facility. The Administrator was not present for the annual visit but S1 was able to assist the LPA for the annual visit. There are five (5) residents who currently reside within the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.


· LPA observed that the facility did not have a current Infection Control Plan on file in place.

Physical Plant/Environment Safety:

· The facility is a single-story house located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents, of which one (1) resident may be bedridden, and they also have a hospice waiver approved for two (2) hospice residents. It has four (4) client rooms, a dining/living room, a kitchen, one shared restroom which had a hot water temperature reading measured at 105.2 Degrees F which also held the facility’s washing and drying machine, a second shared client bathroom attached to Room #2 which had a hot temperature reading of 109.2 Degrees F, and a front and back yard patio area.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 08/16/2024 04:07 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/15/2024 at 02:40 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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(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
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Based on record review, LPA observed there was no current Infection Control Plan on file at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Administrator will send a copy of the current Infection Control Plan to the LPA by the POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility did not have a urrent copy of liability insurance on file in place which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Administrator will send a copy of the current liability insurance to the LPA by the POC due date.
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
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2024 04:07 PM - It Cannot Be Edited


Created By: Daniel Konishi On 08/15/2024 at 02:48 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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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During record review, LPA unable to review five (5) staff, Admin, S1 to S4 personnel records and staff training records due to the facility could not produce the files and staff training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Administrator will send Admin, S1 to S4 personnel records and staff training records to the LPA by the POC due date.
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During medication review, LPA observed MARs (Medication Administration Record) for R1 to R4 were inaccurate and not up to date as the MARs for all residents were last initialed for May 14th, 2024. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Administrator will submit a written statement indicating that they will ensure that the residents' MARs are accurate and up to date.
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
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE INC.
FACILITY NUMBER: 198601665
VISIT DATE: 08/15/2024
NARRATIVE
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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has one (1) fully charged fire extinguisher located near the kitchen of the facility.

· Cleaning supplies were observed in a secured area in the kitchen.

· Sharps were observed in a secured area in the kitchen.

· Carbon monoxide detector is tested and in working condition.

· Water temperature readings measure between the required 105 - 120 degrees Fahrenheit in compliance with Tile 22 Regulations.


Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for six (6) non-ambulatory residents, one (1) of which can be bedridden, and a hospice waiver approved for two (2).


· Care and supervision to meet the clients’ needs was observed.
· LPA observed that facility did not have a current Liability Insurance on file in place to review.

Staffing:

· A total of five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· LPA unable to review five (5) staff Admin, S1 to S4 (Staff #4) personnel records and staff training due to the facility could not produce the files and staff training which were not available to review during the visit.


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE INC.
FACILITY NUMBER: 198601665
VISIT DATE: 08/15/2024
NARRATIVE
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Resident Rights/Information:

· Physician orders were reviewed in resident files.

· Personal Rights is posted.

· Facility provides phone and internet access to residents.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, and medication records were reviewed.


· During medication review, LPA observed the MARs for R1 (Resident #1) to R4 (Resident#4) recorded was dated May 1st, 2024 and the last initialed on the MARs was on May 14th, 2024 which is inaccurate.
Food Service:
· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· Resident medical and dental records in resident files.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· An emergency and disaster drill was last conducted on 04/07/2024

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided to S1.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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