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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602543
Report Date: 07/01/2021
Date Signed: 07/01/2021 11:43:57 AM

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:
07/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Jiezl Mate - Lead Caregiver TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit to follow up on previous visit on 5/26/21. LPA Flores met with Jiezl Mate - lead caregiver and explained the reason for the visit.

On 5/26/21 LPA(s) Flores and Mora observed facility had 2 bedridden residents #1(R1) and #2(R2) and were working on obtaining a fire clearance to allow them to have the 2 bedridden residents at the facility. A follow up with fire department determined fire clearance for 2 bedridden residents has been denied.

On 7/1/21 LPA Flores conducted a review of residents documents for Residents #2(R2), #3(R3), #4(R4) and #5(R5), and observed R1 is no longer at the facility since R1 has passed away on 6/10/21 and facility submitted a death report on 6/14/21 to the department. Based on documents reviewed there is currently 1 bedridden resident, 2 non ambulatory residents, and 1 ambulatory resident. Facility is licensed to serve 6 non-ambulatory residents, of which 1 may be bedridden and is currently under serving under license requirements.

During this visit LPA observed R5 has half bed rails on bed R5 is not under hospice and does not have a doctor request for half bed rails. Deficiencies will be cited for Title 22 Regulations on LIC 809D.

Exit interview was conducted with Jiezl Mate, lead caregiver and a copy of the report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: AURA
FACILITY NUMBER: 198602543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2021
Section Cited

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87608 Postural Supports: a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions. (3) A written order from a physician... shall be maintained in the resident’s record...

This requirement is not met as evidence by:
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Based on LPA's observation and documents reviewed facility did not ensure R5 has a physician written order for half bed rails on file, LPA observed R5 has half be rails on his bed which poses an immediate Health, Safety, or 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: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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