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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002100
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:15:01 PM

Document Has Been Signed on 12/03/2024 01:15 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOMERSET HOMEFACILITY NUMBER:
306002100
ADMINISTRATOR/
DIRECTOR:
LENETTE L. BELENFACILITY TYPE:
735
ADDRESS:4950 SOMERSET ST.TELEPHONE:
(714) 739-2273
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6CENSUS: 6DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:Lenette Belen - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Lenette Belen, Administrator and explained the purpose of the inspection.

The facility is one-story building with 4 client rooms, 2 bathrooms, kitchen, dining room, living room, staff room, enclosed patio, den, laundry area, office area, backyard and 2-car garage. All client rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed the facility to be in good repair. LPAs observed two exit gates that are self-latching and unlocked. Facility has toxins, chemicals and cleaning supplies locked in a cabinet in the laundry area. LPAs observed sharps to be locked in a drawer in the kitchen. Restrooms are stocked with soap, paper towels and air dryers. LPAs observed facility has emergency food and water supply as well as additional emergency supplies. LPAs observed the fire extinguishers are full as indicated by the meter on them. LPAs observed the service tags on the extinguishers stating they were serviced in April of 2024. LPAs reviewed 5 staff files and 4 client files. LPAs reviewed the P&I and medication for all clients. Based on medication review, LPAs observed handwriting on a client's prescription label. Facility staff stated the label was written on by facility staff. A deficiency is being issued. Facility staff could not provide LPAs with a medication administration record for a client's PRN medication taken. A deficiency is being issued. LPAs conducted interviews with 4 staff. Clients present were non-verbal and unable to be interviewed by LPAs. Based on review of the facility's emergency disaster plan, LPAs determined the disaster plan to be incomplete. A deficiency is being issued. LPAs issued a Technical Violation regarding Admission Agreements. LPAs provided advising on Admission Agreement policy. Facility staff was advised to draft a new Admission Agreement for the facility that includes all Title 22 Requirements and to have clients and/or their responsible parties sign these new Admission Agreements. Facility staff was advised to maintain both agreements in client files.



Based on today's inspection, three deficiencies and one technical violation are being issued. An exit interview was conducted and a copy of this report, deficiency pages and appeal rights were provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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 12/03/2024 01:15 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 12/03/2024 at 12:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SOMERSET HOME

FACILITY NUMBER: 306002100

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(3)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to discrpencies between physical medication and the medication administration record. This poses a potential health or safety risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Administrator stated they will conduct an in-service training regarding protocol related to receipt of client Medication from the pharmacy and accurate record-keeping. AD stated they will conduct the training by the assigned due date. AD stated they will document the training with the following information: date/time the training was conducted, participating staff and topics covered. AD stated they will email the mentioned documentation to the LPA by the assigned POC due date.
Type B
Section Cited
CCR
80075(k)(4)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (4) No person other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above due to presence of facility staff handwriting on at least one client prescription label. This poses a potential health or safety risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Administrator stated they will conduct an in-service training regarding Medication storage and labels. AD stated they will conduct the training by the assigned due date. AD stated they will document the training with the following information: date/time the training was conducted, participating staff and topics covered. AD stated they will email the mentioned documentation to the LPA by the assigned 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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/03/2024 01:15 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 12/03/2024 at 12:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SOMERSET HOME

FACILITY NUMBER: 306002100

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to presence of an incomplete Emergency Disaster Plan (LIC610D). This poses a potential safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Administrator stated they will complete any unanswered questions or prompts in the Emergency Disaster Plan and Emergency Disaster Manual. AD stated they will conduct an in-service training regarding Emergency Disaster Protocol to ensure facility staff is aware and able to enact the Emergency Disaster Plan. AD stated they will send to the LPA via email a document with the date/time of the training, staff in attendance and topics covered by the assigned POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
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