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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603085
Report Date: 04/02/2024
Date Signed: 04/02/2024 04:59:40 PM


Document Has Been Signed on 04/02/2024 04:59 PM - 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:NEXGEN SENIOR HOME CARE LLCFACILITY NUMBER:
198603085
ADMINISTRATOR:WOODS, TEJONFACILITY TYPE:
740
ADDRESS:1009 S CITRUS STTELEPHONE:
(626) 727-6233
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:6CENSUS: 6DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Kacey Ung, Lead CaregiverTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Lead Caregiver Kacey Ung. The following 12 (CARE) tool domains were utilized during the inspection:

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan.


Operational Requirements:
  • A current Plan of Operation was reviewed. The facility serves residents 60 years and older, has a Dementia Waiver in place, and a Hospice Waiver for four (4) residents is approved.
  • A fire clearance for 5 non-ambulatory and (one) 1 bedridden resident is place.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 5/15/2024. A surety bond is not applicable. Facility does not handle resident's money.

Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 2 may be bedridden. It consists of a kitchen, living room, dining room, outdoor patio area, laundry area in attached garage, 4 resident bedrooms, 1 staff bedroom, 2 private bathrooms, 1 common bathroom, and one 1/2 bathroom in the staff room.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were not locked. Cleaning supplies and toxic substances were observed unlocked under the kitchen sink. Citations were issued.
  • Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. Water temperature in 2 out of 4 bathrooms was 143.4DF and 136.8 DF. Citation was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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: NEXGEN SENIOR HOME CARE LLC
FACILITY NUMBER: 198603085
VISIT DATE: 04/02/2024
NARRATIVE
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Staffing:
  • A total of 6 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificates expires 5/22/2024.
  • Personnel files were not provided during the visit. Only criminal background clearance and 1st Aid/CPR training was checked. Citation was issued.

Resident Records/Incident Reports:
  • A total of six (6) resident files were reviewed. Files were incomplete. They were missing Physician's Reports, Appraisals/Appraisal Needs/Services Plans, TB clearance, COVID-19 vaccine cards, and Functional Capability Assessment. However, Dementia residents had medical assessment over 1 year old and/or none at all. Citation was issued.
  • RCFE complaint poster and Personal rights were observed posted in the facility hallway.

Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.
  • Physician orders for modified diets are not in place.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
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: NEXGEN SENIOR HOME CARE LLC
FACILITY NUMBER: 198603085
VISIT DATE: 04/02/2024
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Incident Medical and Dental:
  • Three (3) centrally stored resident medications were reviewed, which contained a 30-day supply of medications.
  • Medical and dental transportation is provided by family.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place.
  • The last emergency disaster drill was conducted on 3/1/2024.
  • Residents with Special Health Needs
  • There are three (3) residents receiving hospice care. None are enrolled in home health at this time.
  • Residents (R2 & R3) are not enrolled in hospice and their beds have full bed rails. A citation was issued.
  • Individual Service Plans and Appraisals were not observed in resident files. Citation was issued.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Lead Caregiver Kacey Ung. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 04/02/2024 04:59 PM - 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: NEXGEN SENIOR HOME CARE LLC
FACILITY NUMBER: 198603085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the hot water temperature in 2 out of 4 bathrooms was 143.4DF and 136.8 DF, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator shall submit a hot water temperature log of all sink readings. It shall be tested each shift today and tomorrow. Submit proof of staff training by tomorrow as well.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 residents (R2 & R3) are not enrolled in hospice and their beds have full bed rails; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator shall submit picture proof of correction that the full rails have been removed from their beds. Obtain physician orders for half bed rails and submit a copy of the physician order. Additionally, submit proof of staff 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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 11 of 13


Document Has Been Signed on 04/02/2024 04:59 PM - 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: NEXGEN SENIOR HOME CARE LLC
FACILITY NUMBER: 198603085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 the kitchen "sharp utensils" i.e., knives & scissors, and the cabinet underneath the kitchen sink contained cleaning products that were unlocked; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator shall submit written proof of correction and proof of staff training by tomorrow.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 Dementia resident (R1) had Advil 200 mg & Omega Fish Oil 1400 mg in an unlocked plastic drawer. Per Physician's Report, R1 has Dementia, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Administrator shall submit written proof of correction and proof of staff 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: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 12 of 13


Document Has Been Signed on 04/02/2024 04:59 PM - 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: NEXGEN SENIOR HOME CARE LLC
FACILITY NUMBER: 198603085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that dementia residents (R2 & R6) do not have current (within the last 12 months) medical assessments and/or no medical assessment was on file; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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Administrator shall submit copies of R2- R6 updated Physician's Reports.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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