306005732-3-28-2022-22-AS-PVEZ-CCXNJH-20220328103022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005732
Report Date: 03/28/2022
Date Signed: 03/28/2022 10:30:27 AM

Document Has Been Signed on 03/28/2022 10:30 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:	ASSISTACARE ROSSMOOR		FACILITY NUMBER:	306005732
ADMINISTRATOR:	MACKENZIE, EMALEE		FACILITY TYPE:	740
ADDRESS:	3022 SALMON DR		TELEPHONE:	5623429071
CITY:	LOS ALAMITOS	STATE: CA	ZIP CODE:	90720
CAPACITY:	6	CENSUS: 4	DATE:	03/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:			TIME COMPLETED:	10:40 AM

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 Assistacare Rossmoor. 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) Erika Martinez. Caregiver Evelyn Alfaro was also present. The facility is licensed for 6 non-ambulatory residents. The facility has a Hospice waiver for 3 residents. There are currently 4 residents living in the facility. The facility staff did not when the last emergency disaster drill was conducted. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised ADs to obtain the Complaint poster in the correct size. At 8:40 AM LPA Velazquez conducted a tour of the physical plant along with CG Alfaro. The 1 story home consists of 5 resident bedrooms with 3 bathrooms. The facility also has a living room, sun room, dining room, and kitchen. The 4 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 and postural support bars in the resident bedrooms. CG Alfaro was not sure if there were written physician orders for the bed rails and postural support bars present in the resident files. Throughout the tour of the physical plant LPA observed there were no auditory alarms present on the exit doors which CG Alfaro verified. CG Alfaro informed LPA Velazquez that 2 residents have Dementia. LPA informed CG that regulation requires the use of auditory alarms in the facility that provides care for residents with Dementia. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. 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 observed the bath tub in one resident bathroom had the surface that was peeling off which CG Alfaro verified.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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 3

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: ASSISTACARE ROSSMOOR	FACILITY NUMBER: 306005732
	VISIT DATE: 03/28/2022

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
26
27
28
29
30
31
32

LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 116.6 degrees Fahrenheit in the first bathroom, at 116.7 degrees Fahrenheit in the second bathroom, and at 111.7 degrees in the third bathroom.

LPA Velazquez inspected the kitchen along with CG Alfaro. 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 and carbon monoxide detectors were tested and found to be operational. LPA Velazquez observed unlocked medications belonging to a resident on the door of the refrigerator which CG Alfaro verified. The medications were Insulin and Leukeran 2 mg tablets. LPA immediately instructed CG to remove the unlocked medications and carefully lock them so that they are inaccessible to residents. Toxins and sharps were locked and inaccessible to residents. First Aid kit was checked and it was missing scissors which CG Alfaro verified. The facility did have a First Aid guide and LPA Velazquez advised CG Alfaro to obtain an updated First Aid manual.

LPA Velazquez along with CG Alfaro toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and the exit gate was 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 CG Alfaro 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 caregivers.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Caregivers Erika Martinez and Evelyn Alfaro and a copy of this report along with the appeal rights, LIC 9102TV 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: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/28/2022 10:30 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: ASSISTACARE ROSSMOOR	FACILITY NUMBER: 306005732
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(j)

87705(j) Care of Personswith Dementia. The licensee shall have an auditory device or other staff alert 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 5 out of 5 doors which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2022
	Plan of Correction
1 2 3 4	Licensee to install auditory alarms on every exit door and submit written proof to LPA by POC due date.

Type A

Section Cited

CCR

87608(a)(3)

87603(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 for 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 4 out of 4 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2022
	Plan of Correction
1 2 3 4	Licensee to obtain a written physician's order indicating the need for the postural supports and submit copies of the orders 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: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3