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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801723
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:00:33 PM


Document Has Been Signed on 03/01/2022 01:00 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:PRIMROSEFACILITY NUMBER:
425801723
ADMINISTRATOR:DOROTHY BERGERFACILITY TYPE:
740
ADDRESS:4630 SONG LANETELEPHONE:
(805) 310-6996
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:14CENSUS: 11DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Dorothy BergerTIME COMPLETED:
01:10 PM
NARRATIVE
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On 03/1/22 at 10:45 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Dorothy Berger, Owner Margaret Halsell, Staff (S1) Susan Halsell and explained the purpose of the visit.

At 10:50 a.m., LPA, administrator, owner, and S1 observed the door to the kitchen was open from the outside. LPA entered the kitchen and observed an unlocked cabinet containing cleaning products. 3 Aerosols cans were stored in the cabinet, Brilliance Food Grade Stainless Steal Cleaner, WD-40, and one disinfectant aerosol. LPA observed 3 cleaning spray bottles with content mostly emptied, and 2 small bottle identified as Hibiclens, an antispectic/Antimicrobial Skin Cleaner. LPA observed another door leading to the kitchen was also open. Dementia residents were present in the room adjacent to the kitchen. Administrator and owner inquired staff how cabinet was unlocked. Staff replied that cleaning was recently done and cabinet was not locked. Administrator and the owner locked the cabinet. LPA issued citation under Title 22, Division 6 Chapter 8 Article 12. Dementia 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
At 11:00 a.m., LPA observed PUB 475 posted in the main dining room. PUB 475 was in the size of 8.5"x11". LPA referred to Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right, 87468 (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. At 11:30 a.m., LPA reviewed Infection Control Module with Administrator and S1. All items in Infection Control Module were checked off as yes. LPA made recommendation to rearrange signs for better visibility. (Continued on 809C)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/01/2022 01:00 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: PRIMROSE
FACILITY NUMBER: 425801723

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 5 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Administrator locked the cabinet. Administrator and Business Manager will post sign to keep caibnet locked after usage and send proof to LPA by 3/2/22.
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: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: PRIMROSE
FACILITY NUMBER: 425801723
VISIT DATE: 03/01/2022
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For example, hand washing signs on the bathroom were posted on the outside of the door. As a result, residents would not be able to see the sign when the door is closed. Infection Control Module was addressed with Administrator and S1 to satisfaction.

LPA issued deficiencies on 809D, conducted exit interview, and emailed report and appeal rights to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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