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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602543
Report Date: 05/26/2021
Date Signed: 05/26/2021 02:46:32 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:AURAFACILITY NUMBER:
198602543
ADMINISTRATOR:PINCHES III, JOHN LFACILITY TYPE:
740
ADDRESS:5602 WHITEWOOD AVETELEPHONE:
(310) 933-8275
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:6CENSUS: 4DATE:
05/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:John Pinches III AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst(s) LPA Mary Flores and Luis Mora conducted a pre-licensing visit at the facility, during the pre-licensing visit due to change of ownership deficiencies were observed and discuss with the current administrator John Pinches III.

The following was observed during the visit:
  • Bathroom #1(B1) water temperature was measured at 125.2 degrees F. Bathroom #2(B2) water temperature was measured at 123.2 degrees F which is not within the required range of 105 - 120 degrees F.
  • Medication cabinet was not locked and contained PRN medication with out doctor's prescription for resident #1 who is no longer at the facility.

During file review the following was observed:
  • Resident #2 last physician's report dated: 11/20/2018 no current physician's report and appraisal/needs and service plan per regulations residents with dementia need to be assess every year.
  • Resident #3(R3) - Physician's report dated: 9/2/2020 states R3 is bedridden, no appraisal/needs and service plan, and Resident #4 (R4)- Physician's Report dated: 8/27/2020 states R4 is non-ambulatory and bedridden, no appraisal/needs and service plan. Both R3 and R4 are under hospice services.
  • Resident #5 (R5) - does not have a resident appraisal, and needs and appraisal/needs and service plan.

Deficiencies were cited and noted on LIC809D during this visit per Title 22 Regulations.

Exit interview was conducted with John Pinches III administrator and a copy of the report and LIC809D was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: AURA
FACILITY NUMBER: 198602543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2021
Section Cited

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87202 Fire Clearance(a) All facilities shall maintain a fire clearance approved by...county fire department,... Prior to accepting or retaining any ...of persons, ...licensee shall notify the licensing agency and obtain an appropriate fire clearance approved...Marshal. (2) Bedridden persons
This requirement is not met as evidence by:
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Based on observations and documents review Licensee did not ensure to notify Fire Department and CCLD that R3 and R4 are currently beddriden and at the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
*Immediate Civil Penalties have been assess for the amount of $500*
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Type A
05/27/2021
Section Cited

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87303 Maintenance and Operation:(e) Water supplies...shall be maintained...: (2) Faucets used by residents... shall deliver hot water... temperature...shall be ...to automatically regulate... temperature of not less than 105 degree F ...and not more than 120 degree F...
This requirement is not met as evidence by:
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Based on observation Licensee did not ensure water temperature was within the require 105 to 120 degrees F; B1 temperature read 125.2F and B2 temperature read 123.2F which poses an immediate Health, Safety, or Personal Rights risk to the persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: AURA
FACILITY NUMBER: 198602543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/27/2021
Section Cited

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78465 Incidental Medical and Dental Care: (e) For every...nonprescription PRN medication...there shall be a signed, dated written order from a physician, ...maintained in the residents file, and a label on the medication....
This requirement is not met as evidence by:
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Based on observation, documents reviewed Licensee did not ensure R#1 PRN medication was prescribed by a physician prior to assisting resident to receive medication which poses an immediate Health, Safety, and Personal rights risk to persons in care.
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Type A
05/27/2021
Section Cited

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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision... stored medication.
This requirement is not met as evidence by:
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Based on observation licensee did not ensure staff kept the medication cabinet lock at all times as LPA(s) observed the medication cabinet in the kitchen was unlock and able to open without a key during the tour which poses an immediate Health, Safety, and Personal rights risk to persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: AURA
FACILITY NUMBER: 198602543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2021
Section Cited

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87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident... which are... disposed...destroyed ...by the facility administrator and one other adult... Both shall sign a record...

This requirement is not met as evidence by:
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Based on observation LPA(s) observed R1 who no longer resides at the facility in medication cabinet in need to be discard which poses a potential Health, Safety, Personal Rights risk to persons in care.
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Type B
06/09/2021
Section Cited

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87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be...:(5) Each resident with dementia shall have an annual medical assessment...

This requirement is not met as evidence by:
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 Based on observation and documents review licensee did not ensure R2 obtained a medical assessment within the last year. Last physician's report was on 11/20/18.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: AURA
FACILITY NUMBER: 198602543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2021
Section Cited

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87705 Care of Persons with Dementia; (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidence by:
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Based on observation and document reviewed Licensee did not ensure R2,R3,R4,R5 were properly assess within the last year which poses a potential Health, Safety, Personal Rights risk to persons in care.
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Type B
06/09/2021
Section Cited

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 87458 Medical Assessment; (b) The medical assessment shall include, but not be limited to:(6) Information applicable to the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal.

This requirement is not met as evidence by:
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Based on observation and documents reviewed licensee did not ensure R5 had a pre appraisal done prior admission which poses a potential Health, Safey, Personal rights risk to persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5