198603421-4-13-2023-28-AS-MGFS-CQUT95-20230413143121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603421
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:31:38 PM

Document Has Been Signed on 04/13/2023 02:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GRANT SERENITY HOMES OF SIERRA MADRE, INC.		FACILITY NUMBER:	198603421
ADMINISTRATOR:	GEVORKIAN, NVARD		FACILITY TYPE:	740
ADDRESS:	425 N. SIERRA MADRE BLVD		TELEPHONE:	(818) 425-6797
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY:	6	CENSUS: 6	DATE:	04/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Maria Agundez - Caregiver		TIME COMPLETED:	02:45 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 using the CARE tool. LPA Flores met with Maria Agundez caregiver and explained the reason for the visit. Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (6) may be bedridden, and has a hospice waiver for (6). The facility is a single home in a residential area and consist of a kitchen, a living/dining room, with 6 resident rooms, 2 bathrooms, a laundry area, a detached garage, a front yard, and a back yard. LPA Flores conducted a tour of the facility with Soila De Dios caregiver and observed the following: Facility is clean, and in good repair indoors and outdoors. Living/dining room has sufficient sitting area. Sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Cleaning supplies, medications, and sharps were observed locked kitchen's cabinets. A medication refrigerator was observed locked. Each bedroom has the required furniture, bedding, and sufficient lighting. Bedroom #2(BR2) was observed with half bed rails for resident #4(R4) a physician's order/request for bed rails was not on file. Bathroom #1 is used as a guest bathroom and water temperature was tested at 112.2 degrees F., bathroom #2(B2) was observed to have grab bars, and a skid mat, water temperature was tested at 110 degrees F., which is within the required 105-120 degrees F. Interlace smoke/carbon monoxide detectors were observed, tested, and in working condition throughout the facility. A fire extinguisher was observed attached to the kitchen wall and last reviewed on 1/30/23. All required postings were observed at the facility. Facility does not have large bodies of water, backyard has shaded sitting area. LPA Flores reviewed medications and files for 5 residents and 5 staff files. Medication for R4 was observed outside original box and without a prescription label and two other medications were observed, which were not recorded in R4's medication sheet. (CONTINUED ON LIC 809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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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Document Has Been Signed on 04/13/2023 02:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY HOMES OF SIERRA MADRE, INC.	FACILITY NUMBER: 198603421
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and review, the licensee did not comply with the section cited above in two medications for R4 were not listed on medication sheet and medication for R2 listed in medication sheet was unable to determined if medication was discontinued per tracking system which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Administrator will provide in-service training for staff and will provide copies of corrected medication sheets for R4 and R2 and in-service agenda and sign-in log by POC due date 4/27/23.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY HOMES OF SIERRA MADRE, INC.	FACILITY NUMBER: 198603421
	VISIT DATE: 04/13/2023

NARRATIVE

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Medication for Resident #2(R2) listed in medication sheet for the month of April not tracked and staff were not if medication has been discontinued. LPA reviewed emergency disaster plan last reviewed on 12/22 and observed emergency food/water supplies stored in the garage. Last fire drill was conducted on 9/29/22.

LPA Flores interviewed 3 staff and 3 residents during the visit. Administrator certificate for Nvard Gevorkian was observed #6050643740 expiration date: 12/23/22 and reviewed renewal is pending in our department. A copy of liability insurance was requested.

Deficiencies will be noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Nvard Gevorkian Administrator and a copy of this report, LIC 809D, technical violaiton, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 04/13/2023 02:31 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY HOMES OF SIERRA MADRE, INC.	FACILITY NUMBER: 198603421
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(4)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and review, the licensee did not comply with the section cited above in medication for R4 was observed without a label and outside original box which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Administrator will obtain original label and box and submit a picture of medication to the department by POC due date 4/14/23.

Type A

Section Cited

CCR

87608(a)(5(A)

87608 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. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 in BR2 was observed with half bed rails and no physician's request/order was on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	Administrator removed the half bed rails from the R4's bed. Deficiency cleared during the visit.

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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC809 (FAS) - (06/04)

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