366426087-8-17-2024-56-AS-MMAE-D88PQV-20240817113146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366426087
Report Date: 08/17/2024
Date Signed: 08/17/2024 11:31:57 AM

Document Has Been Signed on 08/17/2024 11:31 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
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:	08/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anchalee Phumirat		TIME COMPLETED:	11:35 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. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Indoor and outdoor passageways were free of obstruction. The facility as no swimming pool or outdoor bodies of water. The facility has a covered outdoor patio area and self-latching backyard gate. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. The facility has operating fire/carbon monoxide alarms and telephone service. Posters such as personal rights, Ombudsman telephone number, Community Care Licensing complaint telephone number, emergency disaster plan, and emergency phone numbers were posted in a common area. Sharps and cleaning solutions were kept locked, inaccessible to residents in care. Review of facility's emergency drill training reveals, last staff training was conducted in July 2023. Kitchen and dining areas were maintained clean. The facility’s refrigerators had sufficient space for food storage and maintained in healthful manner. The 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. Resident’s bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space, and sufficient lighting. Resident’s bathrooms were equipped with grab rails and operating in safe and sanitary condition. The hot water temperatures measured at 117 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

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: 08/17/2024

NARRATIVE

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Resident's medications were centrally stored in a locked cabinet; However, review of residents medication records reveals records a not current. The administrators stated that some of Resident #1(R1s) prescribed medications are temporarily not being administered to R1 due to their effects on R1; However, there is no documentation to of the effects or doctors/nurses orders to stop administering the medication.
Facility staff records reviewed had First Aid Certifications, fingerprint clearances/exemptions, health screenings, and training. LPA review of resident's records reveals Resident #2 (R2) did not have have tuberculosis results on file.

Deficiencies were cited during today's visit per the California Code of Regulations and Health and Safety Codes. An exit interview was conducted, where this report was discussed and a copy was provided to the Licensee with Appeal Rights at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2024 11:31 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
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: 08/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not administering R1's medication as prescribed; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit a statement of understanding of regulation cited and proper medication management 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: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 08/17/2024 11:31 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
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: 08/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of Resident #2 tuberculosis (TB) clearance/results which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit documentation of resident's TB results by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review, the licensee did not comply with the section cited above by last drill conducted with staff was in July 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/02/2024
	Plan of Correction
1 2 3 4	The Licensee shall submit to the Licensing Agency documentation of emergency drill conducted with staff 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC809 (FAS) - (06/04)

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