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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602785
Report Date: 11/22/2024
Date Signed: 11/22/2024 03:40:07 PM

Document Has Been Signed on 11/22/2024 03:40 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BERLAND HOME CAREFACILITY NUMBER:
374602785
ADMINISTRATOR/
DIRECTOR:
PARAISO, DENNISFACILITY TYPE:
740
ADDRESS:512 BERLAND WAYTELEPHONE:
(619) 205-4600
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:53 PM
MET WITH:Caregiver Thea Capili and Administrator May ParaisoTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 11-21-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Thea Capili. LPA then met with Co-Administrator May Paraiso, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. According to care records, staff interviews, and LPA observation: During this annual inspection, there were a total of six (6) residents in care [Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), and Resident #6 (R6)], of whom all were non-ambulatory, per their respective doctors. [See LIC811 Confidential Names list pages for a description of select person identifiers used in this report.] The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA interviewed multiple residents and multiple staff. LPA reviewed the care records for all residents and the personnel and training files for all staff. LPA also toured the interior and exterior of the facility, and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.


[CONTINUED ON LIC 809-C, 1 of 3]
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not store tools, and other items that could constitute a danger, inaccessible to residents with dementia. This posed an immediate safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 11/22/2024
Plan of Correction
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During LPA's site visit, Licensee locked away the tools and hazardous items, resolving the immediate risk. Licensee agreed to lead a training for facility staff on what items could become hazardous if left accessible to residents, and the importance of keeping them locked away. Licensee agreed to E-mail the training sign-in sheet to LPA, by 12/22/2024
Section Cited

87465 Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that centrally stored medications were kept locked and not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This posed an immediate health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 11/22/2024
Plan of Correction
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During LPA's site visit, Licensee locked the cabinet where the centrally stored medicines were kept, and resecured the keys, resolving the immediate risk. Licensee agreed to lead a training for facility staff on storage requirements related to medications, and the importance of maintaining facility keys on one's person. Licensee agreed to E-mail the training sign-in sheet to LPA, by the 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.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
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Based on records review and manager interview, Licensee did not possess a completed and signed health screening for 2 of 9 staff (S2 and S3). This posed a potential health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to have S2 and S3 both go to a doctor in order to each complete an LIC503 Health Screening. Licensee agreed to E-mail the completed and signed LIC503 forms with negative tubeculosis (TB) test result for S2 and S3 to LPA, by the POC due date. Licensee agreed to add the completed LIC503 forms to the personnel records for S2 and S3.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 6 of 6 residents (R1 through R6) were regularly observed for changes in physical functioning, in include unusual wieght gains or losses. This posed a potential health risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to measure, and record in a log, the body weights for R1 through R6. The method can be a scale, or if this is not possible for the resident, another method (such as measuring body fat with a tape measure). Licensee agreed to send proof of weight assessment for R1 through R6 to LPA, by the POC due date. Going forward, Licensee agreed to periodically measure and record resident's body weights, and to keep such records accessible at the facility.
Section Cited
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 9 of 9 facility staff (S1 through S9) were trained in the proper use of all required PPE annually. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to conduct PPE training for all current staff. The training will include hands-on practice and will cover: a) how perform an N-95 seal check, b) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and c) how to set up and manage an isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat and document this training at least once per year.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87309 Storage Space: “(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on LPA observation, Licensee did not ensure that disinfectants, cleaning solutions, and other items which chouse pose a danger if readily accessible to clients, were stored where inaccessible to them. This posed an immediate health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 11/22/2024
Plan of Correction
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During LPA's site visit, Licensee locked away the disinfectants and cleaning solutions, resolving the immediate risk. Licensee agreed to lead a training for facility staff on what items could become hazardous if left accessible to residents, and the importance of keeping them locked away. Licensee agreed to E-mail the training sign-in sheet to LPA, by 12/22/2024
Section Cited
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not maintain at the facility a personnel record on 1 of 9 staff (S1). This posed a potential health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to E-mail to LPA the following for S1, by the POC due date: LIC501 Personnel Record, LIC503 Health Screening with negative tuberculosis (TB) result, and LIC508 Criminal Record Statement. Going forward, License agreed to maintain at the facility a current personnel file on S1 at all times.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 1 of 9 staff (S2), who was subject to a criminal record review, requested and received approval for a transfer of a criminal record clearance, prior to working at the facility. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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CCLD records showed that S2 possessed a current Criminal Record Clearance. However, S2 was not yet associated to the facility roster. Licensee agreed to either use Guardian or E-mail the necessary forms to associate S2 to the facility's staff roster, by the POC due date. If updating in Guardian, Licensee will E-mail LPA upon completion of that process. If submitting forms to the CCLD regional office via E-mail, Licensee will Cc: LPA Nguyen.
Section Cited
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
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Based on records review and manager interivew, Licensee did not ensure that 1 of 6 residents (R4) had an examination for communicable tuberculosis, as evideced by a diagnosic test. This posed a potential health risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to coordinate with R4's responsible person, doctor, and/or hospice agency, as needed, to accomplish either a PPD test or a chest X-ray to rule out tuberculosis (TB) for R4. Licensee agreed to E-mail proof of the negative TB result to LPA, by the POC due date. Licensee agreed to add R4's TB test result to their care file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, for 6 of 6 residents (R1 through R6), Licensee did not arrange a meeting with the resident and appropriate individuals identified in Section 87467(A)(1) to review and revise the written record of care at least once every 12 months. This posed a potential health and personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to author an LIC625 Appraisal/Needs and Services Plan (or equivalent care document) for R1 through R6, then meet with each of those residents' responsible persons (RPs) to discuss and improve the Plans, as needed. Licensee agreed to E-mail the completed LIC625s, with RP signatures, to LPA, by the POC due date. Licensee agreed to add these documents to the resident's care files, and to calendar care conferences with each RP at least annually to sign updated LIC625s.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on records review and manager interview, Licensee did not ensure that 9 of 9 facility staff (S1 through S9) were trained annually on the facility's written Emergency Disaster Plan, and the staff's responsibiltiies during an emergency or disaster. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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3
4
Licensee agreed to conduct training for all current staff on the facility's LIC610E Emergency and Disaster Plan. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licnesee agreed to repeat and doucment this training at least once per year.
Section Cited
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 records review and manager interview, Licensee did not conduct disaster drills at least quarterly for each shift. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to conduct, and document in writing, competion of three (3) disaster drills (one for AM shift, one for PM shift, and one for NOC shift). Licensee agreed to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of emergency covered from quarter to quarter, and to maintain documentation of such.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 11/25/2024 05:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on records review and manager interview, for 3 of 6 residents (R1, R3, and R4) who were under hospice care, Licensee did not ensure that the hospice agency provided training to 9 of 9 staff (S1 through S9), specific to the current and ongoing needs of the individual resident receiving hospice care, before such care began. This posed a potential health and personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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3
4
Licensee agreed to coordinate with the hospice agencies for R1, R3, and R4, to arrange for personnel from those agencies to conduct seperate in-service training for all current staff. The training sessions will cover the Hospice Care Plans and the current and ongoing needs of R1, R3, and R4, respectively. Licensee agreed to E-mail the training sign-in sheets to LPA, by the POC due date. Going forward, Licensee agreed to have the hospice agency training facility staff each time (and before) a new resident goes onto hospice care services.
Section Cited
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and manager interview, Licensee did not ensure that 4 of 6 residents (R2, R4, R5, and R6), who were each diagnosed with Dementia, had a medical assessment and reappraisal done at least annually. This posed a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
1
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Licensee agreed coordinate with the responsible persons (RPs) and physicians, as needed, to ensure completion of updated LIC602 Physician's Reports for R2, R4, R5, and R6. Licensee agreed to E-mail the completed and signed LIC602's to LPA, by the POC due date. Licensee agreed to add these documetns to those residents care files. Going forward, Licensee agreed to obtain updated LIC602s at least one a year for any resident diagnosed with Dementia.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain an auditory device or other staff alert feature to monitor exits on 2 of 4 exterior exit doors which residents had direct access to. This posed a potential safety risk to 4 of 6 residents in care (R2, R4, R5, and R6) who were diagnosed with Dementia.
POC Due Date: 12/31/2024
Plan of Correction
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During LPA's site visit, Licensee added a working auditory staff alert device to both of the referenced exit doors. The Plan of Correction is Satisfied. Going forward, Licensee agreed to periodically test door sensors, and replace them when needed.
Section Cited
87411 Personnel Requirements – General: “(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records and interviews, Licensee did not ensure that 2 of 9 staff (S4 and S5) had current first aid training from a qualified agency. This posed a potential health and safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to coordinate with S4 and S5 to have each person complete First Aid Training from a qualified agency. Licensee agreed to E-mail S4 and S5’s updated First Aid Certification cards to LPA, by the 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.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…” This requirement was not met, as evidence by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain ongoing compliance with the facility’s prior approved fire clearance. This posed an immediate safety risk to 6 of 6 residents (R1 through R6) in care.
POC Due Date: 11/22/2024
Plan of Correction
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During today’s visit, the facility’s Co-Administrator phoned a professional vendor to obtained an appointment to inspect and service the facility’s fire extinguishers on 11-26-2024. Licensee agreed to E-mail to LPA both the paid invoice and photographs of the updated service tags for the facility’s three (3) fire extinguishers, as soon as completed, but not later than 12-22-2024.
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.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited

87459 Functional Capabilities: “(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living…” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review, for 6 of 6 residents (R1 through R6), Licensee did not assess the person’s need for personal assistance and care by determining his/her ability to perform specified activities of daily living. This posed a potential health and personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to complete form LIC9172 Functional Capability Assessment for R1 though R6, and to E-mail them to LPA, by the POC due date. Licensee agreed to add the completed forms to the residents’ care files. Going forward, License agreed to complete the LIC9172 for all new move-ins.
Section Cited
87506 Resident Records: “(b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manger interview, Licensee did not ensure that the care records for 6 of 6 residents (R1 through R6) contained the name, address, and telephone number of a dentist to be called in an emergency. This posed a potential health risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to contact the responsible persons (RPs) for R1 though R6 to ask them who they would like to be the default/preferred dentist for their loved one. Licensee may offer the RPs possible choices, such a mobile/visiting dentist who can visit the facility. Once this information is obtained, Licensee will update the Face Sheets for R1 through R6 with the dentist’s name, address, and phone number. Licensee agreed to E-mail the updated Face Sheets to LPA, by the 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.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87218 Theft and Loss: “(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that an initial personal property inventory was completed for 6 of 6 residents (R1 through R6). This posed a potential personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to coordinate with responsible persons (RPs) as needed to populate form LIC621 (or an equivalent Personal Property Inventory sheet) for R1 through R6. Licensee agreed to E-mail to LPA copies of the competed and signed Personal Property Inventories, by the POC due date. Going forward, Licensee agreed to keep these forms updated in real time, for all current and future residents.
Section Cited
87468 Personal Rights: “(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents…(A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not have signed copies of the latest resident personal rights for 6 of 6 residents (R1 through R6). This posed a potential personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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Licensee agreed to have form LIC613C-2 Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly signed by the responsible persons (RPs) for R1 through R6, and to E-mail copies of such to LPA, by the POC due date. Licensee agreed to file these forms in the residents' care files. Going forward, Licensee agreed to have this forms completed for all new move-ins.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BERLAND HOME CARE

FACILITY NUMBER: 374602785

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/22/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
1569.159 Telephone services and equipment; notice to residents of availability: “The State Department of Social Services shall provide to residential care facilities for the elderly a form, which the residential care facility for the elderly shall attach to each resident admission agreement, notifying the resident that he or she is entitled to obtain services and equipment from the telephone company...” This requirement was not met, as evidenced by:
Deficient Practice Statement
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3
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Based on records review and manager interview, for 6 of 6 residents (R1 through R6), Licensee did not attach to their admission agreement and have signed the required Telecommunications Device Notification form. This posed a potential personal rights risk to persons in care.
POC Due Date: 12/22/2024
Plan of Correction
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2
3
4
Licensee agreed to have form LIC9158 Telecommunications Device Notification signed by the responsible persons (RPs) for R1 through R6, and to E-mail copies of such to LPA, by the POC due date. Licensee agreed to file these forms in the residents' care files. Going forward, Licensee agreed to have this forms completed for all new move-ins.
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.
Lizzette TellezTELEPHONE: (619) 767-2351
Dang NguyenTELEPHONE: (619) 210-9024

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024

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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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BERLAND HOME CARE
FACILITY NUMBER: 374602785
VISIT DATE: 11/22/2024
NARRATIVE
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[CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 74 F. Hot water at taps accessible to residents were also compliant in temperature: Kitchen Sink was 115.3 F, Bathroom #1 Sink was 105 F, and Bathroom #2 Sink was 110.8 F. Appliances to preserve perishable food were compliant in temperature: Kitchen Refrigerator was 39 F, and Kitchen Freezer was 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance.

R1’s doctor wrote that they were sometimes “forgetful. R3’s doctor diagnosed them with Mild Cognitive Impairment (MCI). R2, R3, R5, and R6 were each diagnosed with Dementia, per their respective doctors. For all residents in care, their doctor determined that each required staff assistance with storing and taking their prescribed medications, and that each was not able to safely leave the facility unassisted.

Inside the facility was a cabinet which contained centrally stored medications. Early on during LPA’s visit, the doors of this cabinet were closed but a caregiver’s keys were left inside the lock. Without the direct care staff noticing, LPA was able to open this cabinet and access the centrally stored medications. [LPA immediately secured/locked the cabinet, and the keys were returned to staff.] Inside the facility was a separate cabinet which contained over fifteen (15) bottles of cleaning chemicals, which would have been hazardous to residents diagnosed with Dementia. The doors to this cabinet were initially unlocked. Without the direct care staff noticing, LPA was able to open this cabinet and access the chemicals. [LPA immediately notified staff and with their help, relocked the cabinet.] In the facility’s backyard, LPA observed unlocked/accessible the following “tools and items that could constitute a danger to residents”: one (1) full-length pole saw with serrated metal blade, one (1) full-length scraper tool with sharp metal blade, three (3) full-length shovels with metal spades, one (1) half-length shovel with metal spade, and one (1) full-length bow rake tool with rigid metal teeth. [Facility staff immediately moved these tools to a locked area.]

[CONTINUED ON LIC 809-C, 2 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BERLAND HOME CARE
FACILITY NUMBER: 374602785
VISIT DATE: 11/22/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 3] During the visit, LPA observed, and manager interview confirmed: Licensee did not ensure the facility’s three (3) fire extinguishers had been professionally inspected and serviced within the last twelve (12) months, which was needed to remain in ongoing compliance with the facility’s prior-approved fire clearance. Also, Licensee did not ensure that a working “auditory device or other staff-alert feature to monitor exits” was present on two (2) of the four (4) exterior exit-doors which residents had access to (which is required when caring for persons with Dementia).

During a review of client records, LPA observed, and manager interview confirmed: R4’s doctor wrote that on their LIC602 Physician’s Report (dated 06-08-2023) that they did not have Tuberculosis (TB). However, Licensee did not have written proof of a negative TB test result or chest X-ray for R4, which was required before R4 moved-in. [During the inspection, R4 did not show signs/symptoms, observable to the layperson, of active TB infection] For R2, R4, R5, and R6, Licensee did not ensure they had a LIC602 Physician’s Report (or equivalent Medical Assessment) updated within the last year, which was required for residents diagnosed with Dementia. For R1 through R6, Licensee did not complete a Functional Capabilities Assessment (or equivalent determination of the resident's ability to perform specified activities of daily living), as required. For R1 through R6, Licensee did not complete a Needs and Services/Care Plan (or equivalent “written record of care the resident will receive in the facility [and] the resident’s preferences regarding the services provided at the facility”), as required. There was also no evidence that Licensee held a care conference meeting with the respective responsible persons (RPs) for R1 through R6, within the last twelve (12) months, as was required. For R1 through R6, Licensee did not ensure their care records contained the name, address, and telephone number of a dentist to be called in an emergency, as required. For R1 through R6, Licensee did maintain a Personal Property Inventory, which was required to be completed with the resident and/or their representative at time of move-in. For R2, R3, R4, and R6, Licensee did not maintain a copy of the Resident’s Personal Rights, signed by the resident and/or their representative, in the resident’s record, as required. For R1 and R5, there was a copy of signed Resident’s Personal Rights, but the version of the form used was outdated/obsolete, and thus incomplete. For R1 through R6, Licensee did not maintain a Telecommunications Device Notification form, signed by the resident and/or their representative, as required. Also, Licensee did not maintain a record of body weights for R1 through R6. (Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”)

[CONTINUED ON LIC 809-C, 3 of 3]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
Page: 16 of 17
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BERLAND HOME CARE
FACILITY NUMBER: 374602785
VISIT DATE: 11/22/2024
NARRATIVE
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[CONTINUED FROM LIC 809-C, 2 of 3]

During a review of personnel and training records, LPA observed, and manager interview confirmed: Licensee did not maintain at the facility a personnel file on Staff #1 (S1), as required. Staff #2 (S2), who had worked at the facility since 2022, possessed an active background clearance from CCLD to work in care facilities, per a check of CCLD’s Guardian database. However, Licensee did not ensure that S2 was associated to the facility’s roster of staff, as required. Licensee did not ensure S2 and Staff #3 (S3) had a completed and signed Health Screening (or equivalent pre-employment physical), as required. Licensee did maintain proof that Staff #4 (S4) and Staff #5 (S5), both of whom provided direct care to residents, had current First Aid Training from a qualified agency, as required. Interview of S4 confirmed they were missing this training. R1, R3, and R4 were current hospice care patients. However, Licensee did not have proof that S1 through Staff #9 (S9) were trained by each residents’ hospice agency on the resident’s “current and ongoing needs,” as required. Licensee did not have proof that S1 through S9 had received training on the facility’s written Emergency Disaster Plan within the last year, as was required. Also, Licensee did not have proof that S1 through S9 had received training on Personal Protective Equipment (PPE) within the last year, as was required. Licensee did not have proof of completion of disaster drills within the last two (2) years. Interview of manager confirmed disaster drills were not conducted. (Regulation required Licensee to drill each shift at least once per quarter).

Nineteen (19) deficiencies were cited per California Code of Regulations, Title 22, and three (3) deficiencies were cited per California Health and Safety Code
(refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding a needed Hospice Exception Request for R1 (refer to the LIC9102-TV page).

An exit interview was conducted with Administrator May Paraiso, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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