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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602285
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:34:01 AM


Document Has Been Signed on 02/17/2022 11:34 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SERENITY CARE HEALTH EVERGREENFACILITY NUMBER:
198602285
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:131 SEGOVIA AVENUETELEPHONE:
(626) 699-4609
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:6CENSUS: 3DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Belen Taico, CaregiverTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza and Baptiste conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Terri Reynolds and explained the purpose of the visit. House Manager Robin Aquino was explained the purpose of the visit telephonically. Staff Belen Taico arrived at the end of the visit. The facility is a single story home located in a residential area licensed for (6) residents over the age of 60. The facility consists of 4 bedrooms, living room, dining room, 2 bathrooms, kitchen, laundry area, patio area, and detached garage. Administrator certificate expires 8/21/2022.

The following were observed/inspected:
· The interior and exterior physical plant was inspected.
· COVID-19 Infection Control signs that promote were observed in the entrance and and bathrooms that
promote hand washing, cough/sneeze etiquette, and physical distancing. Visitor screening is in place.
· Private rooms are designated as a COVID-19 isolation rooms if needed.
· Staff was observed wearing a surgical mask.
· Residents in care do not wear masks due to cognitive impairment and/or health condition.
· Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed.
· Sufficient supply of Personal Protective Equipment (PPEs) was observed.
· Staff files were not reviewed today.
***** Three (3) centrally stored resident medication records were reviewed. Medication errors for Residents R1 & R2 were observed. AM medications were not dispensed yesterday, and physician orders were not observed.
Deficiencies were cited. See LIC 809D.
Exit interview was conducted with staff Belen Taico. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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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Document Has Been Signed on 02/17/2022 11:34 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: SERENITY CARE HEALTH EVERGREEN
FACILITY NUMBER: 198602285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during medication review, the licensee did not comply with the section cited above in that resident (R1's) AM medications Memantine HCL 5MG, Levothyrozine Sodium 25 M5 MCG, and Nifedipine ER 60 mg were not administered on 2/16/2022. In addition, 1 loose orange medication was observed in the medication bin; which poses an immediate health, safety or personal rights risk to persons in care. Refresh Tears does not have a physician order.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee shall submit a written plan of correction. All med-tech and direct care staff will be provided medication administration training. This training shall be provided by a pharmacy and/or registered nurse. Submit proof of training by tomorrow.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) 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 resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that resident (R2) had medication sodium chloride hypertonicity [ophthalmic solution 5%] that did not have a physcian order, nor was documented in the centrally stored medication records. In addition, there was a loose white medication pill in the medication bin; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee shall submit a written plan of correction. Staff medication training by a pharmacy and/or registered nurse shall be conducted. Submit proof of training by tomorrow.

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 HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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