306005496-3-30-2022-22-AS-PVEZ-CCZQW6-20220330123126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005496
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:31:32 PM

Document Has Been Signed on 03/30/2022 12:31 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:	GENTLE SENIOR CARE		FACILITY NUMBER:	306005496
ADMINISTRATOR:	MIRABUENO, MARIA PRICILLA		FACILITY TYPE:	740
ADDRESS:	4193 TERESA AVE		TELEPHONE:	(213) 446-1695
CITY:	CYPRESS	STATE: CA	ZIP CODE:	90630
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Surajudeen Sadiq - Caregiver Pricilla Mirabueno - Administrator		TIME COMPLETED:	12:45 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 Gentle Senior Care. 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 Caregiver (CG) Surajudeen Sadiq. Administrator (AD) Pricilla Mirabueno arrived later to assist with the visit. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. There are currently 5 residents living in the facility with 2 currently receiving hospice services. The last emergency disaster drill was conducted on February 15, 2022. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised AD Mirabueno to obtain the Complaint poster in the correct size. At 10:50 AM LPA Velazquez conducted a tour of the physical plant along with CG Sadiq. The 1 story home consists of 5 resident bedrooms with 3 bathrooms. The facility also has a living room, family room with dining area, and kitchen. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails in the resident bedrooms. One resident had 2 half bed rails on each side of the bed essentially creating a full bed rail. Per CG Sadiq the resident is not receiving hospice services. CG Sadiq was not sure if there were written physician orders for the bed rails present in the resident files. During the tour of the physical plant LPA observed one resident bedroom did not have an auditory alarm present on the exit door which CG Sadiq verified. CG Sadiq informed LPA Velazquez that 3 residents in care have Dementia. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. One of the 3 toilets did not have a working toilet handle which CG Sadiq verified.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: GENTLE SENIOR CARE	FACILITY NUMBER: 306005496
	VISIT DATE: 03/30/2022

NARRATIVE

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LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 110.6 degrees Fahrenheit in the first bathroom, at 114.2 degrees Fahrenheit in the second bathroom, and at 104.5 degrees Fahrenheit in the third bathroom.

LPA Velazquez inspected the kitchen along with AD Mirabueno Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke detectors were tested and found to be operational. The carbon monoxide detector was inoperable and CG Sadiq replaced it with one that was in operating condition. Medications, toxins and sharps were locked and inaccessible to residents. First Aid kit was checked and it was missing tweezers which AD Mirabueno verified. The facility did not have a First Aid manual and LPA Velazquez advised AD Mirabueno to obtain an updated First Aid manual.

LPA Velazquez along with AD Mirabueno toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were not clear of hazards as LPA and AD observed a door, broken pieces of furniture, a toilet, and the exit gates were not operational. 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 Mirabueno to ensure a written physician's order indicating the need for the bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with AD Mirabueno and provided a copy of said regulation. AD Mirabueno acknowledged receiving a copy of this regulation..

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Pricilla Mirabueno 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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/30/2022 12:31 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: GENTLE SENIOR CARE	FACILITY NUMBER: 306005496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

87705(h) Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 exit gates which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the exit gates have self-closing latches in operating condition at all times and submit written 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: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/30/2022 12:31 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: GENTLE SENIOR CARE	FACILITY NUMBER: 306005496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)

87608(a) (3) Postural Supports. 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 himself/herself. Postural supports may be used under the following 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 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 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2022
	Plan of Correction
1 2 3 4	Licensee to ensure there is a written physician order indicating the need for the postural supports is present in a resident's record and submit written proof to LPA by POC due date.

Type A

Section Cited

CCR

87705(j)

87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff feature to monitor exits, if exiting presents a hazard to any resident.
	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 3 doors which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2022
	Plan of Correction
1 2 3 4	Licensee to ensure there are auditory alarms present on every exit door 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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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