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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603665
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:24:05 PM

Document Has Been Signed on 07/23/2024 04:24 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:PRISTINE CARE 1FACILITY NUMBER:
198603665
ADMINISTRATOR/
DIRECTOR:		VANKINA, VENKATESWARAFACILITY TYPE:
735
ADDRESS:14639 DALMATIAN AVETELEPHONE:
(720) 272-7437
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 4CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:23 PM
MET WITH:Venkateswara Vankina - Administrator TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit following the completion of a complaint visit which was conducted on 7/23/2024 and is relation to the complaint investigation control number 28-AS-20240715113138. LPA met with Venkateswara Vankina, Administrator for the facility, and explained the purpose of the visit.

During the course of the complaint investigation, it was revealed that a former resident of the facility Client #1 (C1) suffered a seizure at the facility on 7/1/2024. Following this incident the client's parent arrived at the facility, and decided on their own accord that C1 should be given their seizure medication, and the parent administered the medication themselves to C1. The facility staff however still marked on the client's Medication Administration Record (MAR) that they had provided C1 their anti-seizure medication, however the staff did not in fact administer this medication, which led to the facility have an inaccurate client file for C1.

The deficiency is noted on LIC809D per Title 22 Regulations.

Exit interview was conducted with caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 07/23/2024 04:24 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 07/23/2024 at 03:31 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: PRISTINE CARE 1
FACILITY NUMBER: 198603665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
80070(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This regulation is not met as evidenced by:
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**POC Cleared** Administrator emailed LPA training materials, attendees, and certificates during the visit.
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Based on interview and record review, LPA determined that facility staff had marked on C1's MAR that they administered a medication to them, however they never did administer the medication to the client, which posed a potential health and safety risk to clients in care.
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Administrator is to ensure that the MARs for all clients are recorded correctly by the facility staff. Administrator is to hold a training on medication administration with staff and submit the attendees of the training along with training materials to the LPA by the POC due date.

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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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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