198602190-9-1-2021-11-AS-JJOS-C6FUAH-20210901152445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602190
Report Date: 09/01/2021
Date Signed: 09/01/2021 09:41:23 PM

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:	CASA DEL SOL RESIDENCE		FACILITY NUMBER:	198602190
ADMINISTRATOR:	JACOBS, DOV E		FACILITY TYPE:	740
ADDRESS:	11606 11602 W WASHINGTON BLVD		TELEPHONE:	(323) 678-4426
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90066
CAPACITY:	12	CENSUS: 2	DATE:	09/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Valorie Hansen, Head Nurse		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced visit to Casa Del Sol Residence. The purpose of today’s visit was to conduct the annual inspection. LPA met with Head Nurse, Valorie Henson. Facility is licensed for 12 non-ambulatory residents. The facility currently has 2 ambulatory resident. LPA Jones toured the physical plant and reviewed staff and resident records.

The facility has 3 bedrooms and 3 bathrooms. The facility conducted a fire drill on 8/16/20121.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate residents comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Food and meals are prepared in the main kitchen located in the skilled nursing facility and is brought to the residents on carts. Staff provided LPA with a waiver. LPA was unable to tour kitchen due to covid 19 restrictions. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA was unable to review administrator file and certificate during the visit but was advised by staff that a temporary administrator is standing in while the active administrator is out of town.

Cont C

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SOL RESIDENCE	FACILITY NUMBER: 198602190
	VISIT DATE: 09/01/2021

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During the visit, LPA observed the facility infection control practices. LPA observed a screening station with sanitizer in the facility entrance and additional sanitation supplies in nursing office inaccessible to the residents . LPA observed a sign in sheet and temperature log for visitors. LPA's temperature was checked during the visit. LPA observed staff wearing mask. Each resident has their own individual room for isolation and required postings are throughout the facility. Staff advised LPA that visitors can meet with residents with an appt.

Deficiencies cited on 809D

Exit interview conducted

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DEL SOL RESIDENCE	FACILITY NUMBER: 198602190
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(a)

Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator… …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement is not met as evidenced by:: LPA was unable to verify administrator certification during the visit or verify stand in staff qualifications who substitute while the administrator is out of town.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review , the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2021
	Plan of Correction
1 2 3 4	The adminsitrator will send verification of his adminstrator certificate and send documentation of current staff credentials who are substituting when he is absent.

Type B

Section Cited

CCR

87211(a)(1)

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This requirement is not met as evidenced by:The administrator failed to report to licensing that he would be out of town and designate a qualified staff to substitute in his absence.
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above iwhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2021
	Plan of Correction
1 2 3 4	The administrator will send CCL documentation indicating that he understands the reporting requirement of notifying CCL when he is out of town and delegate staff in his absence.

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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC809 (FAS) - (06/04)

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