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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801082
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:43:27 PM


Document Has Been Signed on 04/21/2022 02:43 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:SUPERIOR RESIDENTIAL CARE FOR THE ELDERLY IIFACILITY NUMBER:
425801082
ADMINISTRATOR:ERIC SO HUFACILITY TYPE:
740
ADDRESS:876 BLAKE STREETTELEPHONE:
(805) 268-4787
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 5DATE:
04/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Eric So HuTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Eric So Hu and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured the residential care facility for the elderly. At 1:10 p.m., LPA entered the kitchen and observed prepared resident medication in a cabinet that did not have a lock. LPA informed Administrator that centrally stored medication needed to be locked and accessible only to employees responsible to centrally stored medication. LPA issued citation on 809D. At 1:20 p.m., LPA discussed items in the Infection Control Module and noted that the facility had handwashing signs in all of the bathrooms, but signs reminded employees to wash their hands. LPA advised Administrator that all individuals should wash their hands. The Administrator is fit tested for N95. Administrator has verbally updated visitors, residents, and staff on current Provider Information Notices (PINs) and will provide internet link to PINs on requests. Infection Control module was addressed with Administrator to satisfaction.

LPA conducted exit interview with Administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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Document Has Been Signed on 04/21/2022 02:43 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SUPERIOR RESIDENTIAL CARE FOR THE ELDERLY II
FACILITY NUMBER: 425801082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview; the licensee did not comply with the section cited above in more than 10 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Administrator will have staff keep prepped medication in the same storage unti as other centrally stored medication. Administrator will email LPA of in-service by 4/22/22.
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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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