366426087-8-11-2023-56-AS-MMAE-CULQD7-20230811120416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426087
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:04:26 PM

Document Has Been Signed on 08/11/2023 12:04 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	A & K PRIVATE HOME CARE		FACILITY NUMBER:	366426087
ADMINISTRATOR:	VOODTIKON PHUMIRAT		FACILITY TYPE:	740
ADDRESS:	11490 POPLAR STREET		TELEPHONE:	(909) 478-1482
CITY:	LOMA LINDA	STATE: CA	ZIP CODE:	92354
CAPACITY:	6	CENSUS: 6	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Anchalee Phumirat, Licensee		TIME COMPLETED:	11:50 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) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Anchalee Phumirat, Licensee and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (6) with a current census of (6) residents. Hospice waiver for (6). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. Backyard has a swimming pool which is empty and secured with a locked fence, inaccessible to residents in care. Facility has a covered outdoor patio area and self-latching backyard gate. LPA inspected the kitchen. The facility has three (3) refrigerators which tested between 33 to 43 degrees F. Kitchen hot water temperature is maintained at 111 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. Facility has sufficient cups, plates, and utensils for resident use. LPA inspected resident bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & K PRIVATE HOME CARE	FACILITY NUMBER: 366426087
	VISIT DATE: 08/11/2023

NARRATIVE

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LPA inspected resident bathrooms. Bathrooms are equipped with grab rails and operating in safe and sanitary conditions. The hot water temperatures tested between 109 to 119 degrees F.

LPA did not observe a carbon monoxide alarm, Licensee stated that they will obtain a carbon monoxide alarm today (8/11/23). Deficiency cited.

Facility has operating telephone service on the premises. Posters such as personal rights, Ombudsman telephone number, complaint telephone number, emergency disaster plan, and emergency phone numbers are posted in a common area. An emergency drill conducted on 7/7/23. Sharps, disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care.

Client medications are kept in a safe and locked cabinet inaccessible to residents in care. All medication are labeled and administered as prescribed.

LPA reviewed (3) staff files for First Aid Certifications, fingerprint clearances/exemptions, health screenings, training, employee rights and personnel records. LPA observed staff #1 had incomplete health screening. Licensee stated that they will provide proof of health screening. Deficiency cite.

All residents records reviewed had admissions agreements, physician's reports, personal rights: residential Care for the Elderly, record of safeguarded cash resources records.

Deficiencies are being cited during today's visit and a plan of correction will be discussed with Licensee. An exit interview was conducted, where this reports (LIC809/LIC809D) were discussed and copies of the reports with appeal rights was provided to the Licensee at the conclusion of the visit.
***This is an Amended report, signed by Licensee***

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2023 12:04 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & K PRIVATE HOME CARE	FACILITY NUMBER: 366426087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not having a carbon monoxide alarm in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2023
	Plan of Correction
1 2 3 4	Licensee stated that they will have a carbon monoxide alarm installed at the facility by today (8/11/23). Licensee to submit proof of correction to the licensing agency 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

Page: 7 of 9

Document Has Been Signed on 08/11/2023 12:04 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: A & K PRIVATE HOME CARE	FACILITY NUMBER: 366426087
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review and interviews, the licensee did not comply with the section cited above by staff #1 having an incomplete health screening, missing tuberculosis screening which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee stated that staff#1 has a appointment with medical doctor on September 1st. Licensee to provide proof of completed health screening to the licensing agency by POC 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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