Community Care Licensing

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
	VISIT DATE: 09/05/2023

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87465(f)(1)(2)(3)

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents. (3) The name and telephone number of an ambulance service shall be readily available. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1) had blank Identification and Emergency Information form (LIC 601).
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will complete the Identification and Emergency Information form (LIC 601) for Resident 1 (R1) and submit a copy to CCLD by 09/19/2023.

Type B

Section Cited

CCR

87459(a)

(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 6 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. All 6 residents did not have a Functional Capabilities form (LIC 9172) in their file
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87459 regulations are met at all times. Additionally, the Licensee will complete the Functional Capabilities form (LIC 9172) for all 6 residents and submit a copy to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87208(a)(7)(A)

(a) Each facility shall have and maintain a current, written definitive plan of operation.....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents.... 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 which poses/posed a potential health, safety or personal rights risk to persons in care. There is a caregiver's bed and belogings in an area in the facility that is labeled as an "Open Area" on the facility floor plan sketch. This area should not be use as a caregiver sleeping or living area.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87208 regulations are met at all times. Additionally, the Licensee will remove the caregiver's bed and belongings from the Open Area and submit a statement that they will comply with this section code to CCLD by 09/19/2023.

Type B

Section Cited

CCR

87608(a)(3)

(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 record review, the licensee did not comply with the section cited above in 5 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1) through Resident 5 (R5) all had a bed rail and LPA did not observe a doctor's order for the bed rails on file. The staff could not find the orders either.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, the Licensee will a doctor's order for the bed rails for all 5 residents and submit a copy to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During medication review, LPA observed discrepencies in Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). There were empty medication containers/bubble packs, some bubble packs were full even though it is the 5th of the month, some bubble packs had more than 5 pills missing, pills were taken out of the bubble pack in an out of order way (dates are on the bubble pack for each pill) which made it difficult to verify if residents are getting their medication daily, and staff stated for some residents medication was discontinued, but medication is still in their basket. LPA is unable to determine if medication is being given as prescribed because staff could not provide an explaination for some of the discrepencies, did not have a list with all the medicaiton for each resident written by a doctor, and there was no doctor's discontinuation orders for the medication that staff claimed where discontinued.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will an in-service training regarding this regulation with all staff and submit a sign in training sheet to CCLD by 09/19/2023. LPA recommended that this facility uses a Medication Administrattion Record (MAR) for each resident to track when medication is given.

Type A

Section Cited

CCR

87465(h)(2)

(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 and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Resident 6 (R6) has medication unlocked in the bedroom. R6's Physician Report states that R6 can manage own medication, but R6 shares the bedroom with Resident 5 (R5) and R5's physician report states that R5 cannot manage own medication. Therefore, medication needs to be locked for the safety of Resident 5.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will an in-service training regarding this regulation with all staff and submit a sign in training sheet to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type A

Section Cited

CCR

87465(c)(1)

(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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the visit, staff were unable to provide the LPA with a current/updated medication list for all residents written by the residents' physician. Due to this and not having a Medication Administration Record (MAR), the LPA could not verify if residents had all their medication at the facility and which medications were discontinued.
	POC Due Date: 09/06/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will contact the physician for all 6 residents to confirm and obtain a list of all the medications that each resident should be taking. A copy of these list will be submitted to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. During the visit, the staff could not provide the LPA with a copy of the liability insurance.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Health and Safety Code 1569.605 regulations are met at all times. Additionally, the Licensee will obtain a liability insurance and submit a copy to CCLD by 09/19/2023.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. During the visit, the staff did not know the whereabouts of all staff files and therefore LPA was unable to review any staff files.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87412 regulations are met at all times. Additionally, the Licensee will ensure that all staff files are kept at the facility and submit a copy of the entire file for 4 staff to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87457(c)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 5 (R5) did not have a Resident Appraisal (LIC 603A) on file during the visit.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87457 regulations are met at all times. Additionally, the Licensee will complete a Resident Appraisal (LIC 603A) for Resident 5 and submit a copy to CCLD by 09/19/2023.

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1)'s Physician Report (LIC 602) did not have a physician's signature and Resident 2 (R2) had a blank Physician Report (LIC 602) on file.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87457 regulations are met at all times. Additionally, the Licensee will obtain a Physician Report for both Resident 1 and Resident 2 and submit a copy to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1)'s Physician Report (LIC 602) did not have a TB exam results.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87458 regulations are met at all times. Additionally, the Licensee will obtain a Physician Report with TB results for both Resident 1 and submit a copy to CCLD by 09/19/2023.

Type B

Section Cited

CCR

87608(a)(5)(B)

(a) ..... 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. (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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 3 and Resident 4 are not hospice and have a full bed rail.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, the Licensee will replace the full bed rails with half bed rails, but will need to have a doctor's order for half bed rails for both residents. A copy of the half bed rail doctor's order will be submitted to CCLD by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023

Document Has Been Signed on 09/12/2023 08:08 AM - It Cannot Be Edited

FACILITY NAME: AYANNA HOME CARE	FACILITY NUMBER: 198603457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2023

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe the Complaint Poster (PUB 475) posted at the facility.
	POC Due Date: 09/19/2023
	Plan of Correction
1 2 3 4	Licensee is to ensure that Title 22 Section 87468 regulations are met at all times. Additionally, the Licensee will post the Complaint Poster at the facility by 09/19/2023.

SUPERVISOR'S NAME: Wei Siew Ho TELEPHONE: (323) 981-3969 LICENSING EVALUATOR NAME: Luis Mora TELEPHONE: 323-981-3964 LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023