306001848-4-7-2022-22-AS-PVEZ-CD9PZY-20220407114619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001848
Report Date: 04/07/2022
Date Signed: 04/07/2022 11:46:25 AM

Document Has Been Signed on 04/07/2022 11:46 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFICA ROYALE ASSISTED LIVING COMMUNITY		FACILITY NUMBER:	306001848
ADMINISTRATOR:	EDWARD MASLOBODSKY		FACILITY TYPE:	740
ADDRESS:	15022 PACIFIC ST.		TELEPHONE:	(714) 892-4446
CITY:	MIDWAY CITY	STATE: CA	ZIP CODE:	92655
CAPACITY:	132	CENSUS: 82	DATE:	04/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Edward Maslobodsky - Administrator		TIME COMPLETED:	12:00 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) Patricia Velazquez conducted an unannounced visit to Pacifica Royale Assisted Living Community. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Activities Coordinator (AC) Ala Yarashevich. Administrator (AD) Edward Maslobodsky arrived later to assist with the visit. The facility is licensed for 66 ambulatory and 66 non-ambulatory residents. The facility also has a hospice waiver for 3 residents. The last emergency disaster drill was conducted on March 17, 2022. LPA was provided with a copy of the most recent Fire Authority permit which is dated July 29, 2021. LPA was also provided with a copy of the most recent liability insurance policy. At 9:01 AM LPA Velazquez conducted a tour of the physical plant along with AC Ala Yarashevich. The facility consists of 3 stories with 66 resident rooms each with their own bathrooms. The resident rooms are located on the second and third floors with the first floor referred to as the basement floor. The facility has 1 activity room/TV room, Bingo room, 1 dining room, kitchen, medication room, hair salon, a library room, 2 connected courtyards, and a lobby area. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed a postural support bar on one of the resident beds as well as bed rails. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in 10 resident bathrooms and the temperature ranged from 109.9 degrees Fahrenheit to 116.9 degrees Fahrenheit verified by AC Ala Yarashevich. LPA Velazquez along with AC Yarashevich tested the signal system and found one room had an inoperable alarm which was verified by AC Yarashevich.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICA ROYALE ASSISTED LIVING COMMUNITY	FACILITY NUMBER: 306001848
	VISIT DATE: 04/07/2022

NARRATIVE

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LPA Velazquez inspected the kitchen along with AC Ala Yarashevich. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. Emergency food supply was also checked and adequately stocked. Fire Extinguishers throughout the facility were fully charged. Toxins, sharps, and medications were locked and inaccessible to residents. First Aid kit was checked and found to be in order. The facility had a First Aid guide and LPA Velazquez advised AD Maslobodsky to obtain an updated First Aid manual.

LPA Velazquez along with AC Ala Yarashevich toured the outside grounds and no bodies of water were observed. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AD Maslobodsky to ensure a written physician's order for the bed rails and the postural support bar is present in the resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Edward Maslobodsky and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2022 11:46 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICA ROYALE ASSISTED LIVING COMMUNITY	FACILITY NUMBER: 306001848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

87608(a)(3) Postural Supports. (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do fro himself/herself. Postural supports may be used under the follwoing conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident;s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 cases which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee to ensure there is a written order from a physician indicating the need for the postural support maintained in the resident's record and submit copies of the physician's order to LPA by POC due date.

Type A

Section Cited

CCR

87303(i)(1)(A-C)

87303(i)(1)(A-C) Maintenance and Operation. (i) Facuilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each residnt's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 9 rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the signal system is in operating condition in all resident rooms and bathrooms at all times and submit written proof to LPA 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

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