198603647-8-6-2024-28-AS-EZAA-D7W29S-20240806171224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603647
Report Date: 08/06/2024
Date Signed: 08/06/2024 05:13:12 PM

Document Has Been Signed on 08/06/2024 05:13 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:	KONICE CARE INC		FACILITY NUMBER:	198603647
ADMINISTRATOR/ DIRECTOR:	WILSON-EKAUN, JOHN		FACILITY TYPE:	735
ADDRESS:	14511 NEARGROVE ROAD		TELEPHONE:	(562) 273-0434
CITY:	LA MIRADA	STATE: CA	ZIP CODE:	90638
CAPACITY: 4		CENSUS: 2	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Olive Garnett - DSP		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Olive Garnett, Direct Support Staff (DSP) for the facility, and explained the purpose of the visit. Administrator John Wilson was notified of the visit by phone call. There are currently two (2) ambulatory clients residing in the facility.

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.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a completed infection control plan.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) ambulatory clients between the ages of eighteen (18) through fifty-nine (59). It consists of four (4) client bedrooms, a kitchen, a dining room, a living room, multiple storage rooms, a laundry area, a backyard with a shaded covering, and two (2) bathrooms of which restroom #1 had a hot water temperature rating of 105.6 degrees Fahrenheit, and restroom #2 had a hot water temperature reading of 105.8 degrees Fahrenheit. Knives along with the chemicals and cleaning supplies are kept locked and inaccessible to clients.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024

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 08/06/2024 05:13 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 08/06/2024 at 04:34 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KONICE CARE INC	FACILITY NUMBER: 198603647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(e)

Personnel Records

(e) All personnel records shall be maintained at the facility site. 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 with all staff members, because none of them have any of their personnel record at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that personnel records are maintained at the facility at all times. Administrator is to email the personnel records of all staff members at the facility to the LPA 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

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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: KONICE CARE INC	FACILITY NUMBER: 198603647
	VISIT DATE: 08/06/2024

NARRATIVE

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·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. There are no pools are or bodies of water accessible to the clients. Fire alarm system is operational. The facility has multiple fully charged fire extinguishers that are kept throughout the facility that were fully charged. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.

Operational Requirements:

· The Program Design was reviewed.

· Fire clearance was approved for four (4) ambulatory clients between the ages of eighteen (18) through fifty-nine (59).

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

· Sufficient staff was observed to be provided for the care and supervision of the clients.

Personnel Records/Staff Training:

· There were no personnel records available for review at the facility including 1^st Aid/CPR training, health screenings, and TB clearances.

· One of the staff members was observed working without a criminal record fingerprint clearance.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Two (2) client 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, nutritional assessments, medication records, and Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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: KONICE CARE INC	FACILITY NUMBER: 198603647
	VISIT DATE: 08/06/2024

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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

· None of the clients of the facility have a restricted health condition or restricted health care plan.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Two (2) centrally stored client medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incidental Medical and Dental:

· All clients have a Needs and Services Plan on file.

· There were no staff training on record.

Disaster Preparedness, and Emergency Intervention:

· An Emergency Disaster Plan LIC610D is kept in the facility.

· The facility has only had clients for two (2) weeks and has not conducted an emergency and disaster drill.

Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

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

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 08/06/2024 05:13 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 08/06/2024 at 04:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KONICE CARE INC	FACILITY NUMBER: 198603647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(2)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing, or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or. 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 1 out of 3 staff members, because one staff who works at the facility does not have a criminal record or fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that all staff working at the facility are fingerprint cleared prior to working at the facility at all times. Administrator is to have the identified staff member fingerprint cleared and associated to the facility 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

LICENSING EVALUATOR NAME:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC809 (FAS) - (06/04)

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