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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603040
Report Date: 07/29/2021
Date Signed: 07/29/2021 10:31:02 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:SPRINGVILLEFACILITY NUMBER:
198603040
ADMINISTRATOR:FAN, LINDA LFACILITY TYPE:
740
ADDRESS:12755 TORCH STTELEPHONE:
(626) 337-7288
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:43CENSUS: 17DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Linda Fan; AdministratorTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Linda Fan and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following were observed/inspected:
  • LPA and Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, linen room, upstair and downstai lobbies, and medication room. The backyard patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bathrooms and measured at 119.1F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is several carbon monoxide detectors throughout the hallways of the facility. There are several fire extinguisher located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked in a storage room and are inaccessible to residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • A random sample of medications were reviewed. LPA observed Administrator did not have a current record of centrally stored prescription medications for each resident. Administrator indicated Medication Administration Record Sheets (MARS) for residents were not up to date, however she was currently working on them.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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 2
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: SPRINGVILLE
FACILITY NUMBER: 198603040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(A)-(F)
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

(A) The name of the resident for whom prescribed.

(B) The name of the prescribing physician.

(C) The drug name, strength and quantity.

(D) The date filled.

(E) The prescription number and the name of the issuing pharmacy.

(F) Instructions, if any, regarding control and custody of the medication.


This requirement is not met as evidenced by:

LPA observed Administrator did not have accurate, up to date centrally stored prescription medication records for all the residents in care. Additionally, residents Medical Administration Records (MARs) are being used to log the medications, however they were not accurate and up to date.
Deficient Practice Statement
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Based on medication review, LPA observed Administrator did not have current, up to date, centrally stored prescription medication records for the residents in care. Facility uses Medication Administration Record Sheets (MARS) to log medications, however the records were not accurate and up to date for each resident. This poses a potential health, safety, and/or personal rights risk to the residents in care.
POC Due Date: 08/12/2021
Plan of Correction
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Administrator to ensure that a record of centrally stored prescription medications are kept on file for each resident. If Adminstrator uses a Medication Administration Record Sheet (MARS) to log the medications, these records must be accurate. Administrator to provide accurate MARS records for all residents for the month of July by POC due date.
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: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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