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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850229
Report Date: 11/16/2022
Date Signed: 11/16/2022 06:30:09 PM


Document Has Been Signed on 11/16/2022 06:30 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:A CASA TUNNELLFACILITY NUMBER:
425850229
ADMINISTRATOR:SORIANO, APRILYN AFACILITY TYPE:
740
ADDRESS:958 E TUNNELL STREETTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
11/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Aprilyn Soriano, Administrator/LincenseeTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220620111537). LPA met with Administrator/Licensee and explained the purpose of the visit is to issue citations for deficiencies observed during the complaint investigation.
During the complaint investigation of Complaint #29-AS-20220620111537, the following deficiencies were observed:

The licensee did not inform R1’s resident representative when R1 had a change of condition. R1’s pressure injuries worsened, R1 refused to eat, lost weight, complained of pain, and had a significant decline in health condition.

The Administrator/Licensee did not demonstrate they have knowledge of the requirements for providing care and supervision appropriate to the residents, as Licensee retained R1 with prohibited health conditions. R1 was bedridden and depended on others to perform all activities of daily living for them and R1’s pressure injury worsened to stage 4.

The LIC 500 Personnel Report, dated 01/13/2022, lists the administrator’s schedule as Monday through Saturday 7:00am to 9:00pm. It does not list the administrator as a caregiver. The “hourly rounding and routine care logs”, dated 05/01/2022 through 05/24/2022 are initialed by the administrator every hour from 6:00am to 9:00pm, on Monday, 05/01/2022 through Thursday, 05/05/2022 and Saturday, 05/07/2022 and Tuesday, 05/10/2022, which indicates they were a caregiver and not performing administrator duties on those dates and times. The LIC 500 shows one caregiver for each shift except for Sunday does not show any caregiver coverage from 6:00pm to 9:00pm.

Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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: A CASA TUNNELL
FACILITY NUMBER: 425850229
VISIT DATE: 11/16/2022
NARRATIVE
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The facility used a baby monitor in R1’s bedroom to monitor R1.

The Medication Assistance Record (MAR) for the date of 05/26/2022, is initialed by staff as all medications given. The facility progress notes on 05/26/2022 state “R1 refused all medications due to pain”.

The Appraisal Needs and Services Plan, dated 01/13/2022, is missing information on page one (1), has not been updated with R1’s change of condition, and is not signed or dated by R1’s resident representative.

The Register of Residents form, dated 05/09/2022, did not list the required information regarding R1. R1’s name, ambulatory status, information on R1’s physician and resident representative information were missing.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 06:30 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: A CASA TUNNELL
FACILITY NUMBER: 425850229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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87466 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 unual
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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. This requirement was not met as evidenced by:
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Based on record review and interviews, the licensee did not comply with the section cited above in not informing R1’s Medical POA of the multiple changes including a significant decline in health, which posed an immediate health and safety risk to residents in care.
Type A
11/17/2022
Section Cited

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87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met evidenced by:
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Based on records review, the licensee did not comply with the section cited above as R1 was retained with prohibited conditions, was bedridden and depended on others to perform all daily living activities, which posed an immediate health and safety 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 11/16/2022 06:30 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: A CASA TUNNELL
FACILITY NUMBER: 425850229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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87411(a) Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
This requirement is not met as evidenced by:
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Based on records review, the licensee did not comply with the section cited above. The LIC500 Personnel Report did not reflect staff coverage on Sundays from 6:00pm to 9:00pm and did not list accurate hours for the administrator, which posed an immediate health and safety 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 11/16/2022 06:30 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: A CASA TUNNELL
FACILITY NUMBER: 425850229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2022
Section Cited

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87468.2(a)(1)..PersonalRights...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations medical treatment, personal care and assistance, visits, communications...
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This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when the facility used a baby monitor in R1’s bedroom to monitor R1, which posed a potential personal rights risk to residents in care.
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Type B
11/23/2022
Section Cited

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87405(d)(3) Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications...in Sections 87405(d)(1) through (7)... (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by:
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Based on records review, the licensee did not comply with the section cited above when Medication Assistance Record on 05/26/2022 is initialed all medications given, yet facility progress notes state on 05/26/2022 “R1 refused all medications due to pain”, which posed a potentail risk to
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residents in care.
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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/16/2022 06:30 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: A CASA TUNNELL
FACILITY NUMBER: 425850229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2022
Section Cited

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87463(a)(3) Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate…Significant changes shall include but not be limited to (3)... change in the health care needs of the
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resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above by not updating the appraisal with R1's change
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of condition, is not complete with background information, and is not signed or dated by R1’s resident representative, which posed a potential health and safety risk to residents in care.
Type B
11/23/2022
Section Cited

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87508(a)(1)(2)(3) Register of Residents :
The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (1) The resident's name and ambulatory status (2) Information on the resident's attending physican...(3) Informaion
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on the resident's responsible person…
This requirement is not met as evidenced by:Based on records review, the licensee did not comply with the section cited above when the Register of Residents form, dated 05/09/2022, did not list the required information regarding R1, which posed a
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potential health and safety risk to residents in care.
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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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