198603206-10-10-2022-28-AS-JBAE-CK3QB6-20221010120100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603206
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:01:08 PM

Document Has Been Signed on 10/10/2022 12:01 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:	LOVING ARMS RESIDENTIAL CARE FOR SENIORS II		FACILITY NUMBER:	198603206
ADMINISTRATOR:	MACANDILI, EDJESKA MIAN N		FACILITY TYPE:	740
ADDRESS:	11503 THOMAS PL		TELEPHONE:	(408) 893-2746
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	10/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Lordes Bisnar		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/10/22 at 09:20 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Lourdes Bisnar who assisted with today’s visit. The facility is licensed to serve 6 residents age 60 and over. Approved for 6 non-ambulatory, of which 1 may be bedridden. Hospice wavier approved for 6. The facility is a single-story building in a residential area, with a kitchen, dining room, living room, 4 bedrooms, 2 bathrooms, garage and a backyard with shaded area. Fire extinguisher observed fully charged. There are smoke detectors/ Carbon monoxide located throughout the facility, tested and operational. LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications. Report continued 809c

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS II	FACILITY NUMBER: 198603206
	VISIT DATE: 10/10/2022

NARRATIVE

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Bedrooms have the required furniture including bedframes, dressers, and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. LPA toured the kitchen and observed 7 days of perishables and 2 days nonperishable. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials and grab bars. The hot water temperature measured at 110.7- 115.1 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility. Medications reviewed for all residents and LPA observed R1-R3 was missing labels on AM and PRN medications. Facility file reviewed revealed administrator certificate # 6027336740 expire 7/28/2023. Last emergency disaster drill 4/22/22.

Pursuant to Title 22 code of regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted with licensee / Appeal Rights Provided / A Copy of the Report Issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2022 12:01 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: LOVING ARMS RESIDENTIAL CARE FOR SENIORS II	FACILITY NUMBER: 198603206
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)(1)(2)(3)(4)

87465(e)(1)(2)(3)(4) Incidental Medical and Dental Care For every prescription and nonperscription PRN medication for which the licensee provides assistance there shall be a signed, ... and a label on the medication. Both the physcician's order and the label shall contain at least all of the following information. (1) The specific symtoms which indicates the need for the use of the medication. (2)The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 6 residents was missing labels on there AM and or PRN medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2022
	Plan of Correction
1 2 3 4	Administrator will make sure R1-R3 AM and PRN medications are all labeled by POC date. Administrator will take a photo and send it by email to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

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