198601823-10-21-2022-28-AS-LMOA-CKESM4-20221021135919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601823
Report Date: 10/21/2022
Date Signed: 10/21/2022 01:59:34 PM

Document Has Been Signed on 10/21/2022 01:59 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:	DELIGHTFUL AGING I		FACILITY NUMBER:	198601823
ADMINISTRATOR:	TAMANA MEHTA		FACILITY TYPE:	740
ADDRESS:	9223 BROOKSHIRE AVENUE		TELEPHONE:	(562) 622-3686
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90240
CAPACITY:	6	CENSUS: 3	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Jeniffer Bobabilla - Administrator		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met Jeniffer Bobadilla (Administrator) and explained the reason for the visit. The facility is licensed to serve six non-ambulatory residents ages 60 and over and may retain up to six hospice residents. The facility is operating within the scope of its license.

The facility is located in a residential area. A tour of the single-story facility included: 4 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, living room, kitchen, dining area, front yard, backyard, and de-attached garage.

LPA and Jennifer toured the facility and the following was observed: sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Auditory devices were seen on all exit doors which are required for dementia residents and were operating at the time of the visit. The water temperature was tested in the residents’ bathrooms and measured at 112.1, 113.3, and 113.1 degrees F which is within the required 105 - 120 degrees F. The bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. The shower has non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have enough closet space. Resident beds have the required linen and the linen is in good condition. There is extra clean linen and towels in each bedroom. Smoke detectors were observed in each room and throughout the facility and are properly operating. A carbon monoxide was observed in the kitchen and it is properly operating. A fire extinguisher was observed in the hallway which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Knives were found in a kitchen cabinet without a lock and are accessible to residents. The lock of the cabinet under the kitchen sink is not working and the cleaning chemicals are kept in this cabinet. Staff medicine was found in the kitchen refrigerator and are accessible to the residents. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet. The front and backyard are well maintained. There is a shaded seating area for the residents located in the backyard. There are no bodies of water at the facility. Passageways and exits are free of obstruction. (continued to LIC 809C)

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DELIGHTFUL AGING I	FACILITY NUMBER: 198601823
	VISIT DATE: 10/21/2022

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Residents medication are centrally stored in a locked kitchen cabinet. Residents and staff files are centrally stored in a living room cabinet. LPA reviewed medication for 2 of the residents and observed that medications are documented properly and given as prescribed. The other resident has no prescribed medications. LPA reviewed files for all 3 residents and 5 staff. No deficiencies were found with the files. LPA observed administrator certificate for Jennifer Bobadilla - 6055379740 with an expiration date of 03/18/2024.

Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing signs were observed in bathroom. Sufficient hand soap, hand sanitizer, and paper towels were observed. Supply of 30-day Personal Protective Equipment (PPE) was observed in the living room.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (refer to LIC 809D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2022 01:59 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: DELIGHTFUL AGING I	FACILITY NUMBER: 198601823
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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. LPA observed knives in a kitchen cabinet without a lock, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2022
	Plan of Correction
1 2 3 4	Licensee locked the knives during the visit. Additionally, licensee will conduct an in-service training about this section code with all staff and will submit an attendance sheet with staff signatures to CCLD by 10/28/22.

Type A

Section Cited

CCR

87705(f)(2)

87705(f)(2). Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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. LPA observed the cleaning supplies/chemicals under the sink cabinet without a lock and staff medicine in the kitchen's referigerator, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2022
	Plan of Correction
1 2 3 4	Licensee locked the cleaning supplies/chemicals and staff medicine during the visit. Additionally, licensee will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by 10/28/22.

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis Mora	TELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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