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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850222
Report Date: 11/21/2024
Date Signed: 11/21/2024 05:30:35 PM

Document Has Been Signed on 11/21/2024 05:30 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:LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CAREFACILITY NUMBER:
405850222
ADMINISTRATOR/
DIRECTOR:
AQUINO, AMELITA I.FACILITY TYPE:
740
ADDRESS:1934 TULIPWOOD DRIVETELEPHONE:
(805) 878-3409
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:09 PM
NARRATIVE
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At on 11/21/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit related to a complaint finial findings (29-AS-20241104143354) visit being issued on this same visit. LPA met with announced who he is and the reason for the visit.

During the above-mentioned complaint, it was discovered through interviews on 11/05/2024 Licensee/Administrator stated on 11/04/2024, facility staff accidently gave Emergency Medical Technicians (EMT’s) Resident 1 (R1) full resident file, containing documents including but not limited to Pre Admissions Appraisals, Appraisals Needs and Services Plan, Admissions Agreement, Hospital and Physician Visit, Home Heath Care documentation and other documentation. Licensee/Administrator made several attempts to located R1’s file including Calling both hospitals, EMT company, Placement Agency, and R1’s son. On 11/18/2024, Licensee/Administrator sent LPA Jeffries and email that R1’s file was, “nowhere to be found.” On 11/17/2024 LPA Jeffries contacted Licensee/Administrator by phone and requested Incident report for R1 for 11/04/2024 hospitalization and death report for same date. Licensee/Administrator stated, “I was so nervous, I forgot”. Licensee emailed LPA Jeffries incident report on 11/17/2024, and an informal email stating that, facility was “Waiting for the Death Certificate from The Coroner's office to provide a copy.” LPA noted that on 08/29/2023, during a prior complaint investigation, and 12/12/2023 during an annual inspection, and an email on 08/14/2024, the regulation requirements for timely reporting, including where, who and how to report. LPA noted that the incident report and the death report were not submitted to LPA’s email until 12 days after the incident and death. Additionally, Licensee/Administrator did not safeguard Resident information and Resident files to keep for 36 months. LPA noted that the facility is cited for Reporting Requirements [87211(a)(1)(A)]. LPA noted that facility is cited for Resident Records [87506(c)(1) and 87506 (e).]

Exit interview, report read, appeal rights and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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Document Has Been Signed on 11/21/2024 05:30 PM - It Cannot Be Edited


Created By: Mark Jeffries On 11/21/2024 at 11:23 AM
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: LIFETOUCH THE ELEGANT LIVING RESIDENTIAL HOME CARE

FACILITY NUMBER: 405850222

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2024
Section Cited
CCR
87506(c)(1)and(e)

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Resident Records 87506(c)All information and records obtained from or regarding residents shall be confidential.
(1) The licensee shall be responsible fo...r safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available ...
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Licensee agrees to continue to search for R1's missing folder and report by 12/05/2024 that efforts of search and results with incident report submitted to LPA via email.
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.(e)Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was note met by evidence of R1's lost full file and is a potential risk fore residents in care
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Type B
12/05/2024
Section Cited
CCR87211(a)(1)(A)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing ..(A)Death of any resident from any cause regardless of where the death occurred.... the resident within seven days of the occurrence of any
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Licensee agrees to create a facility procedure and standardized resident information form for Emergency Medical Technicians (EMT) when residents are transported to the hospital and sample of all current residents in care by 12/05/2024, via email to LPA
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of the events specified .... This requirement was not met by evidence of R1/s incident report being request past the 10 day submission limits, which poses a risk to residents in care.
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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:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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