198602864-12-5-2024-11-AS-UCOL-DC3T5H-20241218132532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602864
Report Date: 09/18/2024
Date Signed: 12/05/2024 09:48:34 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240909102306

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	STEVEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Gloria Somintac, House Manager (S1)		TIME COMPLETED:	05:39 PM

ALLEGATION(S):

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Staff did not provide resident’s medication as prescribed
Staff do not provide a good quality of food to residents in care
Facility is not adequately staffed resulting in residents' needs not being met
Facility has vermin

INVESTIGATION FINDINGS:

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***The purpose of this amendment is to update the first allegation "Staff did not provide resident’s medication as prescribed" from Unsubstantiated to Substantiated, on the report dated 09/18/2024. This report is being created to include additional observations/record reviews, one additional (1) deficiency and to correct the deficiencies cited on the LIC9099-D.***
On 09/18/2024, The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an initial complaint visit at the above-mentioned facility. CCLD staff were met by Gloria Somintac, House Manager (S1) and later by Steven Gradney, Administrator (S2), and the purpose of the visit was explained.
The investigation consisted of the following: On 09/18/2024 CCLD staff obtained and reviewed facility documents, which included staff facility roster and facility resident roster and copies of Medication Administration Record (MAR), resident physician's reports and invoice from pest control service(s). On 09/18/2024 CCLD staff interviewed three (3) staff and five (5) residents.
Report continues, see LIC9099C.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240909102306

FACILITY NAME:	SENIOR MANOR CARE		FACILITY NUMBER:	198602864
ADMINISTRATOR:	STEVEN GRADNEY		FACILITY TYPE:	740
ADDRESS:	2011 SANTA RENA DRIVE		TELEPHONE:	(310) 989-1941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 5	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	Gloria Somintac, House Manager (S1)		TIME COMPLETED:	05:39 PM

ALLEGATION(S):

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Facility staff do not follow proper sanitation practices.
Staff inappropriately speaks to residents in care.
Staff do not allow residents to have private phone calls.
Staff did not safeguard resident’s belongings.

INVESTIGATION FINDINGS:

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***The purpose of this amendment is to update the unsubstantiated findings, which now include additional record review information*** On 09/18/24,The Department of Social Services, Community Care Licensing Division (CCLD) staff conducted an initial complaint visit at the above-mentioned facility. CCLD were met by Gloria Somintac, House Manager (S1) and later by Steven Gradley, Administrator (S2) and the purpose of the visit was explained.
The investigation consisted of the following: On 09/18/2023 CCLD staff obtained and reviewed facility documents, which included staff facility roster and facility resident roster and copies of Medication Administration Record (MAR) and physician's reports. On 09/18/2024 CCLD interviewed three (3) staff and five (5) residents.
The investigation revealed the following: Allegation #3: “Facility staff do not follow proper sanitation practices.” It has been alleged that staff do not wash their hands after using the restroom, which led to an infection. Interviews revealed that three (3) staff (S1-S3) and three (3) residents (R2, R4-R5) have denied that the allegation has taken place. Report Continues, see LIC9099C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 09/18/2024

NARRATIVE

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Record reviews have revealed that the facility has sent their infection control paperwork to CCLD on 04/11/2021, which verifies that the facility is aware of infectious bacteria and diseases and how to control those infections. CCLD observed appropriate hand sanitization devices throughout the facility and in common areas. Based on CCLD observations, interviews conducted and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Allegation #4: “Staff inappropriately speaks to resident in care.” It has been alleged that staff speak disrespectfully to residents in care. Interviews revealed that three (3) staff (S1-S3) and three (3) out of five (5) residents (R2, R4-R5) have denied that the allegation has taken place. Record reviews have revealed that all staff have completed required cultural competency and resident rights sections during their initial training, 02/05/2021. All staff have continued to be trained on the same sections, during their required yearly training, conducted on 01/19/2024. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Allegation #7: “Staff do not allow residents to have private phone calls.” It has been alleged that staff eavesdrop on residents’ conversation. Interviews revealed that three (3) staff (S1-S3) and three (3) out of five (5) residents (R2, R4-R5) have denied that the allegation has taken place. Record reviews have revealed that all staff have completed required resident rights sections, which include residents' right "to have reasonable access to telephones, to both make and receive confidential calls", during their initial training, 02/05/2021. All staff have continued to be trained on the same sections, during their required yearly training, conducted on 01/19/2024. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Allegation #8: Staff did not safeguard resident’s belongings.” It has been alleged that one resident’s personal belongings have been taken. Interviews revealed that three (3) staff (S1-S3) and three (3) out of five (5) residents (R2, R4-R5) have denied that the allegation has taken place.

Report continues, see LIC9099C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 09/18/2024

NARRATIVE

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Record reviews have revealed that all staff have completed residents rights sections, during their initial training, 02/05/2021. The section has covered "Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff". The licensee shall give the residents receipts for all such articles or cash resources. All staff have continued to be trained on the same sections, during their required yearly training, conducted on 01/19/2024. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was held with Steven Gradney, Administrator (S2), and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 09/18/2024

NARRATIVE

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The investigation revealed the following: Allegation #1: Staff did not provide resident’s medication as prescribed. It has been alleged that staff did not consistently assist giving residents' medication, as prescribed by the resident's Dr.'s orders. Interviews have revealed that three staff (3) and four (4) residents have denied the allegation has taken place, while one (1) resident agreed with the allegation. Record Reviews of the Medication Administration Record (MAR) of June through September 18th, 2024 was conducted. The MAR indicates that R1 had not received one of their medications (M1) between the dates 09/01/2024 - 09/17/2024. Based on CCLD staff’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division six (6), is being cited. Please see the attached LIC 9099D.
Allegation #2: Facility is not adequately staffed resulting in residents' needs not being met.
The details of the complaint alleged the facility is not adequately staffed, and the result is that resident’s needs are not being met. Information provided as follows; there is no present staff at the facility at night, and that resident #1 (R1) is left in soiled diapers until the following morning. On 09/18/24, between 09:38 am – 10:15 am, CCLD staff interviewed (1) out of (1) House Manager staff #1 (S1). (S1) claimed that two residents are incontinent and require continuous bed care. (S1) confirmed that the facility does not have an awake staff. The facility has staff scheduled Sunday-Saturday 07:00 am – 07:00 pm. (S1) claimed there is no staff for care and supervision after 07:00 pm – 07:00 am. (R1-R2) are left with no assistance and (S1) admitted they are left in soiled diapers throughout the evening through early morning.
On 09/18/24, between 10:50 am – 11:30 am, CCLD staff interviewed (2) out of (5) residents #1-#5. (R1-R2) confirmed that they were incontinent and required assistance with diaper changes after 07:00 pm through 07:00 am. (R3-R5) are independent and do not require continuous bed care.
On 09/18/24, between 01:40 pm – 01:50 pm, CCLD staff interviewed home health aide for (R2), witness #1 (W1). (W1) confirmed that (R2) is on home health three days a week. (R2) is incontinent and requires repositioning every two hours. (W1) communicated that (R2) is being treated for wounds and has a wound care plan in place. (R2) is currently diagnosed with a Stage 2 pressure injury in the buttocks area.
As a result of the CCLD staff reviewing service records for (R1-R2), service records confirmed (R1-R2) according to the Physician’s Report LIC 602A (dated: 12/06/22 and 03/08/24) are both non-ambulatory -and-required-continuous-bed-care-and-required-assistance-with toileting. (R1) is bladder and bowel impaired, while (R2) is only bladder impaired.
Report continues, see LIC9099C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 09/18/2024

NARRATIVE

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A review of Personnel Report LIC 500 (dated: 09/12/24) verified no staff scheduled after 07:00 pm through 07:00 am. From 5:00PM TO 5:06PM LPA and S2 held a conversation, where S2 verified that there are two (2) staff who reside at the facility, overnight. Additionally that the staff present at the facility are able to assist residents as needed. Based on CCLD staff’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division six (6), is being cited. Please see the attached LIC 9099D.
Allegation #5: Staff do not provide a good quality of food to residents in care.
The details of the complaint alleged the facility does not provide a good quality of food to residents. Information provided expressed concern about the quality of food due to the presence of vermin in the facility. On 09/18/24, between 09:38 am – 10:15 am, CCLD staff interviewed (2) out of (2) staff, House Manager and administrator (S1-S2). Both S1 and S2 admitted there has been evidence of vermin in the facility and that pest control service plan with Terminix will be continued. (S1) claimed although there has been evident presence of vermin in the facility, there has been no evidence of vermin contamination of food served to residents in the facility. On 09/18/24, between 10:20 am – 10:50 am, CCLD staff inspected the kitchen pantry and refrigerator. CCLD did not observe any evidence of vermin in the kitchen or food prep area. CCLD observed opened bottles/jars stored in the pantry cabinet: (2) ranch dressing(s), (1) honey mustard dressing, (3) barbecue sauces, (1) ketchup, and (1) sweet and sour sauce. These condiments were not stored properly and should be refrigerated for quality. CCLD observed (2) opened/unsealed bags of pasta and (1) sliced mango in the refrigerator, not stored in an airtight container to preserve its quality. Based on CCLD staff’s record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division six (6), is being cited. Please see the attached LIC 9099D.
Allegation: #6: Facility has vermin. The details of the complaint alleged the facility has vermin. Information provided claimed there is a presence of mice in the facility and there has been a lack of action taken to address this issue. On 09/18/24, between 09:38 am – 10:15 am, CCLD staff interviewed (2) out of (2) House Manager and administrator (S1-S2). Both admitted there has been evidence of vermin in the facility and that pest control service plan with Terminix will remain in place. (S1) stated the last pest control service was on 08/06/24, which verified the facility has not received any pest control services within the past six (6) weeks. (S1) stated the Terminix pest control service plan is conducted monthly. (S2) claimed that mouse glue board traps are used throughout the facility to tackle this issue. (S2) claimed that facility staff will be more vigilant to ensure screen doors and windows will remain shut and that all screens are in good repair. Report continues, see LIC9099C.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
	VISIT DATE: 09/18/2024

NARRATIVE

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As a result of the LPA's observations, LPA Dabuet reviewing service records for Terminix Pest Control, it revealed the facility has a regular service, and the most recent service was on 08/06/24, treated for the kitchen and exterior perimeter. Based on the gathered information, there is sufficient evidence to support the allegation mentioned above.

There has been three (3) deficiencies cited during today's visit, please see LIC9099D.

An exit interview was held with Steven Gradney, Administrator (S2), and a copy of the facilities' appeal rights, deficiencies (LIC9099D) and this report have been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/02/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnell...shall be sufficient in numbers...to provide the services...to meet resident needs. Additional staff... employed...to perform...maintenance...and grounds. This regulation has not been met as evidenced by:	1 2 3 4 5 6 7	CCLD staff and Administrator, Steven Gradney (S2), have spoken and have agreed that the administrator/licensee will hire an overnight staff in order to attend to residents' needs while in care. S2 will send an updated LIC500 to LPA Leon, via email, at MARIO.LEON@DSS.CA.GOV
	8 9 10 11 12 13 14	Based on CCLD staff's observation and record reviews, the licensee did not ensure sufficient staff were present at the facility overnight which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 10/15/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 - Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. This regulation has not been met as evidenced by:	1 2 3 4 5 6 7	LPA's and Administrator, Steven Gradney (S2), have spoken and have agreed that the administrator/licensee will submit updated reports on the status of the vermin control to LPA Leon, via email, at MARIO.LEON@DSS.CA.GOV
	8 9 10 11 12 13 14	Based on observation, interviews, and record reviews, the licensee did not ensure the facility was clean, safe and sanitary. Licensee did not ensure the facility was serviced for vermin 6 weeks which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 9

Control Number 11-AS-20240909102306

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SENIOR MANOR CARE	FACILITY NUMBER: 198602864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/18/2024 Section Cited CCR 87555(b)(8)(23)	1 2 3 4 5 6 7	87555 - General Food Service Requirements (b) ...food...requirements shall apply: (8) All food shall be of good quality...(23)...readily perishable foods or beverages...growth of micro-organisms which can cause food infections... appropriate temperature. This has not been met as evidenced by:	1 2 3 4 5 6 7	CCLD and Steven Gradney, Administrator (S2), have agreed that all food items are to be handled and stored appropriately to preserve the best nutritional value. Administrator has agreed to discard the condiments and will ensure that food will follow nutritional guidelines, as suggested.
	8 9 10 11 12 13 14	Based on CCLD Staff observations, the licensee did not store condiments in it's appropriate temperature and cut fruit left in the refrigerator while not properly stored in a sealed compartment which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 09/18/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 - Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed...by each facility. The plan...by obtaining such care...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	CCLD and Steven Gradney, Administrator (S2), have agreed that an in-staff training on medication managment will be conducted with all staff working or residing at the facility. S2 has also agreed for all staff who are assisting residents with their medication to agree, and sign, that Dr.'s orders will be
	8 9 10 11 12 13 14	This has not been met as evidenced by: CCLD Staff reviewed MAR of R1 and observed no record of admission of a medication, between the dates of 09/01/24 - 09/18/24, as ordered by R1's Dr., which poses a potential health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14	consistently met moving forward.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

Page: 9 of 9