306005599-11-23-2022-22-AS-AJLO-CMJUSX-20221228145104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005599
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:25:13 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2022 and conducted by Evaluator Ruth Martinez

COMPLAINT CONTROL NUMBER: 22-AS-20221116173328

FACILITY NAME:	A1 ELDER CARE		FACILITY NUMBER:	306005599
ADMINISTRATOR:	SHAH, BINDI		FACILITY TYPE:	740
ADDRESS:	2538 E LARKSTONE DRIVE #A		TELEPHONE:	(949) 929-5318
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS:	DATE:	11/23/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Bindi Shah		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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-Staff did not provide resident with sufficient room to comfortably and safely accommodate resident.

-Resident bedroom is being used as a passageway to another room, bath or toilet.

INVESTIGATION FINDINGS:

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This unannounced visit conducted by Licensing Program Analyst (LPA) Ruth Martinez is being conducted to initiate the 10 day visit to investigate the above mentioned complaint allegation. LPA arrived at facility was greeted at the door by caregiver and granted entry. LPA met with caregiver and explained the nature of today’s visit. Bindi Shah, Administrator arrived shortly after and met with LPA and explained the nature of the visit and allegations were explained.

Findings are based upon this investigation which included interview conducted and tour of the physical plant of the facility.

It is alleged that staff did not provide resident with sufficient room to comfortably and safely accommodate resident and resident bedroom is being used as a passageway to another room, bath or toilet. LPA Lyman

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221116173328

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: A1 ELDER CARE	FACILITY NUMBER: 306005599
	VISIT DATE: 11/23/2022

NARRATIVE

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conducted a visit on 11/21/22 and revealed the following: Administrator and Licensee state a wall was put up to split a resident room into two private rooms and a permit was not pulled. LPA reviewed facility floor plan which shows the floor plan does not match the actual physical plant. On today’s visit upon observation LPA observed that there was a door in place in the installed bedroom, however that door has been removed since 11/21/22. LPA observed that the air vent was on left side of bedroom on the opposite side of the wall. Interview with resident indicated that since the vent was only on one side of the bedroom the air would not properly circulate due to the placement of the door. Resident indicated that bedroom bathroom would be used by occupants of the bedroom and caregivers. Prior to the wall being added the bedroom was private and R1 was the sole occupant of it. R1 indicated that wall was added around the week of 11/10/22. R1 indicated having an issue once the door and wall was placed because it now became a shared room rather than a private room because with the wall installation and door, it became a passageway to residents’ bathroom by other residents and caregivers and further more was used as a passageway to the other part of the bedroom. Interviews with staff revealed that the wall had been installed about two weeks ago and that the door in bedroom has now been removed permanently and will not be replaced to remain as an open entryway. Staff indicated that the flow of air is now access to all parts of the bedroom. It was indicated that bedroom was used as a passage way to the bathroom by caregivers and access to other parts of the bedroom.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to facility administrator along with appeal rights

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221116173328

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: A1 ELDER CARE	FACILITY NUMBER: 306005599
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/24/2022 Section Cited CCR 87307(a)(C)	1 2 3 4 5 6 7	Personal Accommodations and Services (a) The facility shall be large enough to provide comfortable living accommodations and privacy for the residents (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not being met as evidenced by: Based on observations and	1 2 3 4 5 6 7	Administrator moved R1 and R2 to a new bedroom until bedroom is ready. Bedroom is currently not occupied. Administrator acknowledges that bedroom bathroom will only be used by occupied residents.
	8 9 10 11 12 13 14	interviews conducted LPA determined the facility is not providing comfortable living accommodations and privacy for the residents as a resident bedroom is being used as a passageway to another room and bathroom. This poses an immediate Health and Safety risk to clients in care.	8 9 10 11 12 13 14	Administrator has determined R1 will no longer occupy previous bedroom and stay in new bedroom. R1 is in agreement.
Type A 11/24/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requiement is not being met as evidence by: based on observation and interview R1 was not	1 2 3 4 5 6 7	Administrator moved R1 to a new bedroom and will not return to previous bedroom. Installed door that accompanied wall installed has been permanently removed and will not be reinstalled which will allow flow of heat or air ventilation to flow throughout the bedroom.
	8 9 10 11 12 13 14	provided sifficient room to comfortably and safety accomodate to resident due to wall and door installed didn't allow for heat and air ventilation to circulate to the whole bedroom. This poses an immediate Health and Safety risk to clients in care.	8 9 10 11 12 13 14	Note: Licensee is currently obtaining a building permit for modification to bedroom. In order to have resident occupy bedroom.

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: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC9099 (FAS) - (06/04)

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