198603538-9-21-2023-28-AS-VMAO-CVVT5D-20230921142522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603538
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:26:03 PM

Document Has Been Signed on 09/21/2023 02:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ALL IN CAREHOME		FACILITY NUMBER:	198603538
ADMINISTRATOR:	YAMASHIRO, SHELLY		FACILITY TYPE:	740
ADDRESS:	1158 BEAVER WAY		TELEPHONE:	(626) 698-9615
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 4	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rosalyne Obedoza- Caregiver		TIME COMPLETED:	02:30 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 met with Caregiver, Rosalyne Obedoza and explained the purpose for the visit. Administrator, Shelly Yamashiro, arrived shortly after and assisted with the visit. The facility is licensed to serve (6) elderly adults, ages 60 and over. It is approved for (6) non-ambulatory residents, of which (1) may be bedridden in room#4 only, and has a Hospice Waiver approved for (3). The facility is a single-story home, located in a residential area. The home consists of a living room, (4) residents bedrooms, (2) resident bathrooms, a kitchen, dining room, attached garage, and shaded patio with seating in the backyard. 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 Maldonado obtained a copy of the resident and staff roster, and conducted a tour of the physical plant with assistance of Caregiver, Rosalyne. The following was observed: There is one central entry point for universal entry screening. The facility has an Infection Control Plan approved and in place. There is sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the hallway closet. The physical plant inside and out is clean, sanitary and in good repair. All walkways, pathways, and ramps were observed to be free of obstruction/hazards. All resident rooms were inspected and observed to have the required furniture, bedding, linens, chair, adequate lighting, and closet space. At 9:20AM, LPA observed (2) resident beds to have full bed rails and (1) resident bed had half bed-rails. (Report Continued on LIC809-C...)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 09/21/2023 02:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALL IN CAREHOME	FACILITY NUMBER: 198603538
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 residents medication not having record of dosages for several centrally stored medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will obtain record of prescribed medications for R4 and submit proof to LPA via email by 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/21/2023 02:26 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ALL IN CAREHOME	FACILITY NUMBER: 198603538
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. 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 building a room inside the garage without proper city permits/notification to licensing and using it as a live-in staff room, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee will obtain proper city permits for the room built inside the garage, currently used for live-in staff, or demolish the room if not permitted by the city. Proof to be submitted to LPA via email by POC due date.

Type B

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: 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 (4) of (4) residents without accurate records of centrally stored medications, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Licensee to send LPA, via email, accurate records for centrally stored prescription medications for 4 residents, by POC due date.

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ALL IN CAREHOME	FACILITY NUMBER: 198603538
	VISIT DATE: 09/21/2023

NARRATIVE

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Resident files were reviewed and observed to have written orders indicating the need for the bed rails in place. Each restroom was equipped with a toilet, shower, and wash basin. The restrooms had the required grab bars and non-skid mats/strips. Additional linens and towels for residents were stored in a hallway closet- inspected and observed to be in good repair. All kitchen and laundry equipment was observed clean and operational during today's visit. The water was tested and measured at 112.6*F in bathroom# 1 and 111.3*F in bathroom# 2, which is in compliance. The facility food was inspected and was observed to be sufficient for the amount of residents in care. The requirement was met for 2-day perishables and 7-day non-perishables available. Emergency disaster plan, facility license, personal rights, and complaint procedures are posted as required. The smoke and carbon monoxide detectors were tested and observed to operate properly. Fire extinguishers were observed in the kitchen and in the hallway, with current inspections and were noted to be fully charged. There is a working telephone in the facility for residents to use. No bodies of water were located on the premises. There is adequate seating in common areas for the licensed capacity. Cleaning supplies/toxins were observed stored and locked under the kitchen sink and in the garage, inaccessible to residents. Each entry/exit was equipped with auditory devices and operational. Sharps were observed stored in a kitchen cabinet, locked and inaccessible to residents
At 9:45AM, LPA observed a room built inside the garage that appeared to be new. The room was equipped with (2) beds, a closet, and there was clothing, shoes, and other personal items there. Per Caregiver Rosalyne, she and another staff live at the home and occupy that room. Per Administrator Shelly, the property is leased and is unsure if the Lessors obtained proper permits to build the room. She was unable to provide any proof and it is not indicated in the facility sketch or Pre-Licensing report that the facility was licensed with that room. (4) Resident files were reviewed and observed to be complete with, but not limited to: current health screenings, appraisals, admission's agreements, personal rights, and emergency contact information. (5) Staff files were reviewed and were complete with/but not limited to- fingerprint clearances, health screenings, and proof of required annual training. At 12:15PM, (4) Resident medications were reviewed and observed to not have accurate records for centrally stored prescription medications for 4 residents, and there was no record of dosages for several centrally stored medications for Resident# 4 (R4). Interviews were conducted with (2) staff and attempted with (3) residents, as (1) was out in the community, and the others were busy at the time of the visit.
Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D.
An exit interview was conducted with Caregiver, Rosalyne Obedoza, and a 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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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