198603358-3-8-2023-28-AS-VMAO-CPQ282-20230307160937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 03/07/2023
Date Signed: 03/08/2023 08:59:45 AM

Document Has Been Signed on 03/08/2023 08:59 AM - 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:	SUPERCARE GUEST HOME		FACILITY NUMBER:	198603358
ADMINISTRATOR:	JABONERO, JANICE RACHELLE		FACILITY TYPE:	740
ADDRESS:	13449 BIOLA AVE		TELEPHONE:	(714) 244-5885
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 6	DATE:	03/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Ruby Cruz- Licensee		TIME COMPLETED:	04:30 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 (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA Maldonado met with caregiver Lalineth Escueta and explained the purpose for the visit. Licensee Ruby arrived shortly after to assist with the visit. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA obtained a copy of the resident and staff roster, conducted a tour of the physical plant with assistance from Lalineth, reviewed (5) staff files, (6) resident files, and (6) residents' medications. The facility is a home located in a residential area that consists of (3) shared resident bedrooms, (2) bathrooms, a dining room, living room, attached garage, detached bedroom in the backyard designated for staff, and a shaded patio with seating on the side of the home. It is licensed to serve elderly residents, ages 60 and over. The facility has a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden, has a hospice waiver approved for (4), and approved dementia care plan. There are currently (4) residents on hospice care that have dementia. LPA inspected all resident bedrooms- they had the required bedding, linens, furniture, closet space, and sufficient lighting. LPA observed (1) dementia resident residing in the detached room located in the back yard, that is designated for staff and does not have a fire clearance for non-ambulatory residents. LPA observed (2) residents to have half-bed rails on their beds that did not have a written medical order on file for them. The bathrooms were inspected and were equipped with a shower, toilet, and wash basin. They were operational, in good repair, and observed to have the required grab bars and non-skid mats. The water temperature was tested and measured at 120F, which is in compliance. (Report Continued on LIC9099-C...)*

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
	VISIT DATE: 03/07/2023

NARRATIVE

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The food supplies was inspected and had sufficient perishables and non-perishables for residents in care. All cleaning supplies, toxins, and sharps were stored properly and inaccessible to persons in care.All exit doors, walkways, and pathways were free of obstruction/hazards and no pools or large bodies of water were observed. Auditory devices were observed at all doors and were operational at the time of the visit. The front and backyard are well maintained. A fire extinguisher was observed in the kitchen was a current inspection and observed to be fully charged. The carbon monoxide detector was tested and operational. The fire alarm system is interconnected and had a current inspection. Planned activities are conducted daily and there is sufficient space inside and outside of facility. Resident Rights and Operational Domains were also in compliance. The First Aid kit had the required items and a current First Aid Manual was available.

Infection control practices and Personal Protective Equipment (PPEs) were observed. There was a visitor screening station at the entrance of the facility and precautionary sigange was posted throughout the home. An Infection Control Plan and COVID-19 Mitigation Plan was on file.

All staff and resident files were reviewed and complete. (1) of (4) dementia residents' files had an updated medical assessment, but did not have an updated appraisal. (6) resident medications were reviewed. They observed to be documented properly and were given as prescribed.

(3) staff and (6) residents present at the time of the visit were interviewed.

Per California Code of Regulations and Health & Safety Code, deficiencies were observed and cited during today's visit on the LIC809-D.
Immediate Civil Penalties of $500 were also assessed for violation of Fire Clearance.

An exit interview was conducted with Licensee and copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2023 08:59 AM - 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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(c)(1)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in (1) of (4) dementia care residents residing in a detached bedroom that does not have proper fire clearance for non-ambulatory, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/08/2023
	Plan of Correction
1 2 3 4	Licensee will place resident in a proper non-ambulatory approved room. Pictures of the emptied room and pictures of the resident's new placement room will be provided to LPA via email by the POC due date.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2023 08:59 AM - 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: SUPERCARE GUEST HOME	FACILITY NUMBER: 198603358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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, interview, record review, the licensee did not comply with the section cited above in (2) residents with half bed rails that did not have a written order from a physician, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Licensee will obtain the written order from each resident's physician, in question, to use the bed rails. A copy of the written order will be emailed to LPA by the POC due date.

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in (1) of (4) dementia care residents had a current medical assessment but did not have a current appraisal on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/10/2023
	Plan of Correction
1 2 3 4	Licensee completed a new appraisal for the resident in question during the visit and provided it to LPA for clearance of deficiency.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

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