198603476-6-14-2024-28-AS-EZAA-D68Q9R-20240614115847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603476
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:59:27 AM

Document Has Been Signed on 06/14/2024 11:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	LA MIRADA VILLA FOR THE ELDERLY		FACILITY NUMBER:	198603476
ADMINISTRATOR:	DE HONOR, ELIZA		FACILITY TYPE:	740
ADDRESS:	15005 LA FONDA DR.		TELEPHONE:	(714) 342-8236
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY:	6	CENSUS: 4	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Diane Ragundo - Caregiver		TIME COMPLETED:	12:13 PM

NARRATIVE

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Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Diane Ragudo, caregiver for the home, and was granted entrance to the facility. Administrator Eliza De Honor arrived shortly thereafter. There are four (4) currently living in the facility, all of whom are on hospice.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed.

· Infection control plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents, along with a hospice waiver approved for six (6) residents. The facility consists of a kitchen, two (2) living rooms, two (2) dining rooms, four (4) resident rooms, a staff room, two (2) residents bathrooms of which Restroom #1 had a hot water temperature reading measured at 107.7 Degrees F, and Restroom #2 had a hot water temperature reading measured at 109.2 Degrees F, a backyard patio area, and an attached garage that contains the facility’s washer and dryer machines and emergency food supplies. The facility’s chemicals, cleaning supplies, and knives are kept locked and inaccessible to residents. The facility was observed to be in good repair.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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 06/14/2024 11:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LA MIRADA VILLA FOR THE ELDERLY	FACILITY NUMBER: 198603476
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 5 out of 5 staff members, because staff have not conducted annual retraining on topics related to dementia care, hospice care, postural supports, and restricted health conditions, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Licensee is to ensure that staff will be trained annually on topics related to dementia care, hospice care, postural supports, and restricted health conditions. Administrator is to email LPA the facility's plan on how they will conduct the required annual retraining on the required topics 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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: LA MIRADA VILLA FOR THE ELDERLY	FACILITY NUMBER: 198603476
	VISIT DATE: 06/14/2024

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has two (2) fully charged fire extinguisher located in the kitchen of the facility as well as in the garage.
· Water temperature readings were within the required range of 105 - 120 degrees Fahrenheit.

Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, along with an approved hospice waiver for six (6) residents

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· Five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, certifications, and 1st Aid/CPR training.
· The required twenty (20) hours of annual retraining on topics related to dementia care, hospice care, postural supports, and restricted health conditions has not been conducted by the facility staff.
Resident Rights/Information:

· Physician orders were reviewed for four (4) resident files.

· Medications were also reviewed for four (4) residents.

Resident Records/Incident Reports:

· Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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: LA MIRADA VILLA FOR THE ELDERLY	FACILITY NUMBER: 198603476
	VISIT DATE: 06/14/2024

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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· The last emergency and disaster drill was conducted three (3) month ago in March of 2024.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs:

· All residents have a hospice care plan in their records are in designated non-ambulatory rooms as required by the facility fire clearance.

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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