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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880594
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:01:53 PM


Document Has Been Signed on 04/04/2022 12:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:ASTORIA CARE HOMEFACILITY NUMBER:
331880594
ADMINISTRATOR:ABRUDAN, TEODORFACILITY TYPE:
740
ADDRESS:74101 PORTOLA POINTE LNTELEPHONE:
(760) 674-7213
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:6CENSUS: 6DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Ermina Feliciano, CaregiverTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection with an emphasis on infection control.

LPA met with Caretaker Ermina Feliciano and toured the facility. Present in the facility during time of visit were 6 residents. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings were observed.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities. LPA later discussed infection control practices and procedures with Ms. Feliciano.

A Type B citation was issued at the time of visit as follows:
  1. Prescription medication was not stored in its original prescribed container.

An exit interview was conducted, and a copy of this report along with a copy of the LIC809-D, and Appeal Rights were discussed with and provided to Ms. Feliciano.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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 2


Document Has Been Signed on 04/04/2022 12:01 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: ASTORIA CARE HOME
FACILITY NUMBER: 331880594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of the medications being stored in one time use cups, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Licensee agrees to submit a memorandum of understanding of the regulation in relation to the storage of medication. Licensee to submit via email by POC date to LPA.
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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2