198603500-1-6-2023-28-AS-KRAZ-CMTUUN-20230106145349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603500
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:54:27 PM

Document Has Been Signed on 01/06/2023 02:54 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:	BHAVATHI LLC		FACILITY NUMBER:	198603500
ADMINISTRATOR:	REDDY,LAKSHMI		FACILITY TYPE:	740
ADDRESS:	784 POMELLO DRIVE		TELEPHONE:	(626) 376-7796
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 2	DATE:	01/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Administrator Lakshmi Reddy		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required 1- year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Lakshmi Reddy and explained the purpose of the visit. This facility is licensed to serve six (6) elderly residents over the age of 60 years old and is approved for one (1) hospice resident. The facility is in a residential neighborhood with an open unfenced front yard and enclosed backyard.

The facility is a single-story family residence that consists of a living room, dining room, family room, kitchen, breakfast area, office, laundry room, four (4) resident bedrooms, two (2) full bathrooms, two (2) half bathrooms and an attached three (3) car garage.

LPA made the following observations:

· No signage or postings throughout the facility that promotes handwashing, cough etiquette, and social distancing. No signage was observed at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic. No signage was observed throughout facility to encourage residents to report acute respiratory illness to staff. Alcohol-based hand sanitizer were not observed in every resident room. LPA did not observe the facility license posted in a prominent location. Administrator admitted to removing all that was previously up when pre-licensing visit was conducted. Administrator printed and posted license while LPA was present. LPA did not observe personal rights, nondiscrimination notice, and complaint information postings.

· Administrator Reedy was not wearing face mask upon LPA’s arrival and LPA had to keep prompting Administrator to put mask back on during the visit.

· LPA observed the entrance wall and hallway walls to have a reddish colored spatter. Carpet in hallways has dark colored stains leading into resident bedroom# 3.

* CONT on 809-C

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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

FACILITY NAME: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

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, resident bathroom#1 water temperature was measured at 131.6 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/07/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will lower tempertaure and sendphoto proof of water temperature within the required limits and maintain a log for the next three (3) calender days. Water will be measured and logged every 12 hours.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

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: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87113

Posting of License

The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, license was not posted upon LPA arrival, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/ Licensee later posted license at front door entrance while LPA was present. Administrator/ licensee will keep license posted in prominent location.

Request Denied

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,spatter on entrance wall and hallway walls, thick dust build up on resident bedroom # 1 ceiling fan, darked colored stains on hallway carpet, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/ Licensee will clean walls, ceiling fan and replace carpet in hallway. Must provide photo proof.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2023 02:54 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: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,resident bathroom #2 grab bar near toliet was broken, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will replace grab bar and send photo proof.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, backyard conatined overgrowth of weeds and grass, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will remove all overgrowth of weeds and grass and will maintain the backyard. Photo proof required.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2023 02:54 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: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468(c)(1)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Administrator admmitted to removing all such postings, 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 car
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will re post and send photo proof. Administrator/licensee will ensure postings are not removed while facility is still licensed by this agency.

Request Denied

Type B

Section Cited

CCR

87468(c)(2)

Personal Rights of Residents

(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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Administrator admmitted to removing all such postings, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will re post and send photo proof. Administrator/licensee will ensure postings are not removed while facility is still licensed by this agency.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 5 of 17

Document Has Been Signed on 01/06/2023 02:54 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: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(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, Administraor admittied to removing postings, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will re post and send photo proof. Administrator/licensee will ensure postings are not removed while facility is still licensed by this agency.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/06/2023 02:54 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: BHAVATHI LLC	FACILITY NUMBER: 198603500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87468(d)

Personal Rights of Residents

(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Administrator admitted to removing postings, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will re post and send photo proof. Administrator/licensee will ensure postings are not removed while facility is still licensed by this agency.

Request Denied

Type B

Section Cited

CCR

87212(c)

Emergency Disaster Plan

(c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Administrator admitted to removing postings, 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.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee will re post and send photo proof. Administrator/licensee will ensure postings are not removed while facility is still licensed by this agency.

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: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

Page: 7 of 17

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: BHAVATHI LLC	FACILITY NUMBER: 198603500
	VISIT DATE: 01/06/2023

NARRATIVE

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· Resident bedroom #1 (double occupancy) is not currently occupied but did contain the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen, and the linen is in good condition. Ceiling fan located in this bedroom had a thick layer of dust on the blades.
· Bathroom #1 located inside resident bedroom #1, water was measured at 131.6 degrees F which is not within the required 105- 120 degrees F.

· Bedrooms # 2, 3, and 4 contained the required linen, bedframes, mattress, dressers, lamps, and chairs.

· Resident bathroom #2 water temperature was measured at 118.9 degrees F which is in the required 105-120 degrees F. Grab bar located near the toilet was observed to be broken.

· Resident bathroom # 3 water temperature was measured 106.7 degrees F which is in the required 105- 120 degrees F.

· Resident bathroom #4 water was measured 107.2 degrees F which is in the required 105- 120 degrees F.

· Kitchen was observed to be clean and Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.

· Facility has a gated pool and jacuzzi that are not filled with water and the space is covered with a tarp and there is also a shaded patio area without table or chairs for residents.

· Residents’ medication was reviewed and administered accordingly.

· Administrator refused LPA request to test the fire alarm and instruceted staff to test the alarm by cooking bacon till it promotes smoke.
Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.
An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report, advisory notes and appeal rights were not discussed or reviewed because Administrator refused to review and sign with LPA.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

LIC809 (FAS) - (06/04)

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