198603208-12-6-2022-28-AS-MGFS-CLURZH-20221206122757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603208
Report Date: 12/06/2022
Date Signed: 12/06/2022 12:37:14 PM

Document Has Been Signed on 12/06/2022 12:37 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 III		FACILITY NUMBER:	198603208
ADMINISTRATOR:	BISNAR, LOURDES		FACILITY TYPE:	740
ADDRESS:	11507 THOMAS PLACE		TELEPHONE:	(562) 864-6308
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY:	6	CENSUS: 6	DATE:	12/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Florinda Ventenilla - Caregiver		TIME COMPLETED:	12:45 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	Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, food review, and medication review. LPA Flores met with Florinda Ventenilla Caregiver and explained the reason for the visit. Administrator was notify via telephone call and let LPA know that responsible person will arrive shortly. Edjeska Macandili - Designated Responsible Person arrived 20 minutes later. The facility is licensed to serve six (6) non-ambulatory residents and has a hospice waiver for 6. The facility is located in a residential neighborhood, and consist of four resident bedrooms, two bathrooms, a living room, dining room, kitchen, patio in the back yard, and attached garage. LPA Flores conducted a tour of the facility and observed the following: Living room area: Screening area observed, with visitor's log. No temperature screening conducted. No Cough etiquette, symptoms, social distance signs posted. Kitchen: Food was observed for at least 2 days of perishables and 7 days of non-perishables. Sharps are maintained locked in a drawer across from stove. Cleaning supplies and laundry supplies are maintained in the attached garage which was unlocked at the time of the visit. Dining room has prevention and doffing and donning posters. A covered fireplace was observed. Bathroom #1 (B1) and bathroom #2(B2) in bedroom #1 were observed with grab bars in the shower, skid mats were not observed, toilets are in working condition, water temperature was tested in B1 at 130.6 degrees F. and B2 at 141.2 degrees F. which is not within the required temperature of 105-120 degrees F. Four (4) bedrooms were observed with required furniture, bedding, and sufficient lighting. Resident #4(R4)'s in bedroom #3(BR3) bed was observed with half bed rails no physician's order was observed in residents file. Medication closet was observed in the hallway no lock available and overflow medication is stored above the medication cabinet that was unlocked at the time of the visit. Medication was observed in Resident #2(R2) and #3(R3)'s night stand in bedroom #1(BR1), physician's reports reviewed stated residents may not stored medication. Five (5) residents file's and medication were reviewed and three (3) staff files were reviewed. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

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 8

Document Has Been Signed on 12/06/2022 12:37 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 III	FACILITY NUMBER: 198603208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2022

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature tested in B1 test at 130.6 and B2 test at 141.2 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2022
	Plan of Correction
1 2 3 4	Licensee will ensure water temperature is within the required 105-120 degrees F., at all times will certify via LIC 9098 to the department by 12/7/22.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 garage was unlock at the time of the visit were disinfectans, and cleaning supplies are maintain which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2022
	Plan of Correction
1 2 3 4	Licensee will ensure that staff maintain cleaning supplies, and disinfectants lock at all times will certify via LIC 9098 to the department by 12/7/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 12/06/2022 12:37 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 III	FACILITY NUMBER: 198603208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 medication medication was not in a centrally store area for R2 and R3, medication closet does not have a lock, and medication cabinet was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2022
	Plan of Correction
1 2 3 4	Licensee will ensure medication is centrally stored and unaccessible to residents at all times will certify via LIC 9098 to the department by 12/7/22.

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 R4's bed was observed with half bed rails and there is no physician's order on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2022
	Plan of Correction
1 2 3 4	Licensee will obtain a physician's order and submit a copy to the department by 12/7/22 or will remove the bed rails and submit pictures to the department by 12/7/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 12/06/2022 12:37 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 III	FACILITY NUMBER: 198603208
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 B1 and B2 do not have a skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2022
	Plan of Correction
1 2 3 4	Licensee will provide skid mats in B1 and B2 and submit a picture to the department by 12/13/22.

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

Page: 4 of 8

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 III	FACILITY NUMBER: 198603208
	VISIT DATE: 12/06/2022

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
26
27
28
29
30
31
32

Fire extinguishers were last checked on 2/18/22. No large bodies of water were observed. Smoke/Carbon monoxide detectors were tested and are in working condition.
Administrator certificate was observed for Lourdes Bisnar #6019327408 Exp: 8/9/22. Administrator submitted documents for renewal on 7/20/22 and are still under review.

Deficiencies have been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Edjeska Macandili Responsibly Designee and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022

LIC809 (FAS) - (06/04)

Page: 8 of 8