306004516-1-19-2024-22-AS-KLYN-CZMT4H-20240119132358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004516
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:46:35 PM

Document Has Been Signed on 01/19/2024 02:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ALPER'S CARE HOME		FACILITY NUMBER:	306004516
ADMINISTRATOR:	ALPER OZDEMIR		FACILITY TYPE:	740
ADDRESS:	12192 MAGNOLIA STREET		TELEPHONE:	(714) 539-3735
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92841
CAPACITY:	6	CENSUS: 6	DATE:	01/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Alper Ozdemir		TIME COMPLETED:	01:48 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) Kimberly Lyman conducted an unannounced visit to Alper's Care Home. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Administrator Alper Ozdemir. Facility has an approved hospice waiver for 2 residents and the home currently has 6 residents. There is 1 resident on hospice during today's visit. Alper Ozdemir has an Administrator Certificate expiring on 04/25/2024. LPA Lyman along with Administrator toured the facility at 10:15 AM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of three resident bedrooms, one resident bathroom, one shared hall bathroom, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 10:22 AM, LPA observed Resident 1 (R1) has full bed rails and all residents have a full rail on the inside of the beds facing the wall. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118 and 119 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Resident hygiene supplies are locked and inaccessible to residents. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements. The entry door into the garage is alarmed. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed the locked medication cabinet. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed emergency food and water supply in the garage. Facility has a generator on site. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 1/03/2024. Facility provides activities in the form of cards or exercise. At 11:00 AM, LPA reviewed six resident files and three staff files. Resident files contained required documents CONTINUED ON LIC 809C DATED 01/19/2024

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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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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: ALPER'S CARE HOME	FACILITY NUMBER: 306004516
	VISIT DATE: 01/19/2024

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including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. LPA observed evidence of current liability insurance. At 12:15 PM, LPA observed medication administration and storage. Facility uses a medication administration record and medications are secured.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/19/2024 02:46 PM - 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: ALPER'S CARE HOME	FACILITY NUMBER: 306004516
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Based on the individual's preadmission appraisal, and subsequent changes to that appraisal. Postural supports may be used under the following conditions. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Resident 1 has full bed rails and all residents have full bed rails on the inside of the bed facing the wall. This poses an immediate health, and safety risk to persons in care.
	POC Due Date: 01/20/2024
	Plan of Correction
1 2 3 4	Licensee to remove bed rails and forward proof to LPA by 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: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC809 (FAS) - (06/04)

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