Community Care Licensing

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type A

Section Cited

HSC

1569.17(c)(1)(A)

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, AD admission, the licensee did not comply with the section cited above as one out of two staff providing direct care and supervision upon LPA's arrival does not have criminal record clearance or an exemption, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	AD asked staff to leave and stated staff will no longer be employed, reside, or volunteer at the facility until criminal backgroud clearance or an exemption is obtained.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 as one out of three staff files were not available for review and one out of three staff files reviewed did not contain a health screening, which poses a potential health and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated health screenings would completed for all staff and personnel records maintained. AD will provide LPA with a copy of heatlh screenings via email by POC date.

Type B

Section Cited

CCR

87412(e)

(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and AD admission, the licensee did not comply with the section cited above as staff hours worked are not being documented, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated they will maintain a current LIC500 and staff schedule to ensure staff hours worked are being documented and provide LPA with proof via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, staff interview, and record review, the licensee did not comply with the section cited above as two out of two staff providing direct care and supervision have not completed 20 hours of training, including six hours specific to dementia care, and four hours specific to postural supports, restricted health conditions, and hospice care, before working independently with residents, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be conducted immediately and staff will not be providing direct care and supervision independently until training is conducted. AD stated they will provide LPA with proof of training via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

CCR

87411(c)(6)

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. 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 as two out of two staff files do not idenify on-the-job training, and documentation does not consist of a statement or notation, made by the trainer, of the content covered in the training, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4

Type B

Section Cited

HSC

1569.626(a)(1)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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 as two out of two staff providing direct care and supervision do not have twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be conducted immediately and staff will not be providing direct care and supervision independently until training is conducted. AD stated they will provide LPA with proof of training via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

CCR

87468(c)(2)(A)

(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 and AD admission, the licensee did not comply with the section cited above as Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) 20” x 26” in size is not posted in the main entryway or anywhere else at the facility which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated they will post Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) 20” x 26” in size by the main entryway of the facility and provide LPA with picture proof via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above as all resident medication is prepared a week in advance and transferred from its original container to a weekly medication organizer, which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated all resident medication will be maintained in its originally received container and will no longer be prepared a week in advanced or placed in weekly medication organizer. AD stated staff medication management training will be provided to staff and proof of training conducted will be provided to LPA via email by POC date.

Type B

Section Cited

CCR

87457(c)(1)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. 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 as one out of four resident files does not contain an appraisal which includes an evaluation of the resident's functional capabilities, mental condition and an evaluation of social factors which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated appraisal will be completed and a copy will be provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 02:50 PM - It Cannot Be Edited

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and AD admission, the licensee did not comply with the section cited above as disaster drills are not currently being conducted which poses a potential safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated disaster drills will be conducted and documented to include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. AD will provide LPA with a copy via email by POC date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Armando J Lucero TELEPHONE: (714) 703-2840 LICENSING EVALUATOR NAME: Claudia Gutierrez TELEPHONE: 714-703-2840 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

FACILITY NAME: ARVILINH HOME CARE	FACILITY NUMBER: 306001749
	VISIT DATE: 03/21/2024