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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800830
Report Date: 02/14/2022
Date Signed: 02/14/2022 05:45:51 PM

Document Has Been Signed on 02/14/2022 05:45 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:AMERICAN CARE HOMEFACILITY NUMBER:
405800830
ADMINISTRATOR:LIXIA ZHANGFACILITY TYPE:
735
ADDRESS:1240 EL CAMINO REALTELEPHONE:
(805) 466-9029
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 38CENSUS: 34DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lixia Zhang, Licensee/AdministratorTIME COMPLETED:
04:25 PM
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At 2:00 pm, on 2/14/2022, Licensing Program Analysts (LPAs) Darlene Chavez and Jenny Olson conducted an unannounced annual infection control inspection of the facility above. LPAs met with Maria Lopez, Assistant Administrator, and Lixia Zhang, Licensee/Owner, and explained the reason for the visit. LPAs and administrator toured the facility.

LPAs’ initial tour of the facility resulted in the following observations: At 2:03 pm, LPAs were screened upon entry to the facility by staff, however, the facility does not maintain a visitor log with details for tracking purposes. LPA Chavez instructed licensee to have a separate visitor log with details and screening checks. Licensee will send a photo of the visitor log to LPA Chavez. Between 2:16 pm and 2:44 pm, LPAs observed five fire extinguishers, two of which had no inspection tags and the remaining three were out of compliance due to the last inspection being on 1/11/2021. Licensee will get the fire extinguishers inspected and send a photo to LPA Chavez.

At 2:45 pm, LPAs did not find Provider Information Notices (PINs) nor PIN summaries posted in the facility. Licensee will print PINs and/or PIN Summaries and place in a binder and place in a common area or post on a wall/board in a common area and send a photo to LPA Chavez of PINs/Summaries posted in the facility.

Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: AMERICAN CARE HOME
FACILITY NUMBER: 405800830
VISIT DATE: 02/14/2022
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Between 2:00 pm and 2:05 pm, LPAs observed the licensee not wearing a mask while greeting LPAs and two staff wearing their masks below their noses. LPA Chavez questioned licensee who stated that she had just finished eating. However, licensee was in the hall going toward the entry, not in the dining hall. At 2:03 pm, Staff #1 (S1) greeted LPAs wearing a mask below S1’s nose. LPA Chavez asked S1 to place the mask on properly to which S1 replied that S1 had to go do something and did not immediately place the mask properly on S1’s face. During the tour, LPA Chavez noted that S1 continued to have S1’s mask below the nose, and asked S1 to pull it up over the nose. S1 stated “It falls down.” At 3:30 pm, LPA Olson asked S1 to always have masks on properly, and S1 replied that S1 would, but then walked away without doing so.

The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.


Between 2:16 pm and 2:44 pm, LPA Olson recorded the kitchen sink water temperature at 134 F and bathroom #4 at 140.2 F. The facility’s water temperatures recorded beyond 120 F degrees, therefore, the facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations. This is a violation of CCR regulations.

Pursuant to Title 22, California Code of Regulations, the deficiencies will be cited on 809-D.

At 2:50 pm, LPA Olson conducted the Infection Control mitigation module with the licensee.



Exit interview conducted, deficiencies cited, and report and Appeal Rights emailed to the licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2022 05:45 PM - It Cannot Be Edited


Created By: Darlene Chavez On 02/14/2022 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICAN CARE HOME
FACILITY NUMBER: 405800830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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87468.1 – Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.
POC Due Date: 02/21/2022
Plan of Correction
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Administrator agreed to immediately get all staff trained on infection control and proper mask wearing and provide training records with all staff signatures to CCL by 2/21/22.
Section Cited
Deficient Practice Statement
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80088(e)(1) Furniture, Fixtures, Equipment, and Supplies: Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature...of not less than 105 degrees F and not more than 120 degrees F. Based on observations, the facility failed to ensure that the facility’s water temperatures were maintained at a temperature of 105 F to 120 F which poses an immediate health and safety risk to residents in care.
POC Due Date: 02/15/2022
Plan of Correction
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Licensee has committed to adjust the hot water heater and record water temperatures in the kitchen and bathroom #4 and send videos to LPA Chavez by end of day 2/15/22.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
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