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25 | Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted a Case Management visit during a Compliant investigation. LPM and LPA met with Administrator (ADM)/Licensee Xiuyan Chen.
During today’s visit, LPM and LPA conducted an inspection of the facility to include the living room, kitchen, 3 resident bedrooms, 2 bathrooms, and exterior. LPM and LPA observed the garage area converted into a bedroom occupied by tenant (T1).
Per ADM, tenant (T1) resides at the facility. T1 is ADM’s son-in-law. LPM and LPA met with T1 and T3 and explained the regulations of tenants being fingerprint cleared at the facility and the bedroom which was converted from a garage needs building permit and fire clearance. As a result, the facility has been cited under 80019 Criminal Record Clearance.
LPM and LPA observed another bedroom build in the middle of the backyard as a stand-alone building, tenant 2 (T2) resides. Another bedroom on the left side of the facility (facing the house from the street) and tenant 3 (T3) lives in bedroom. ADM states these bedrooms do not have a fire clearance and do not have a building permit. ADM stated they were built after facility licensure.
LPM and LPA interviewed 5 residents, the administrator (ADM), and two (A1 and A2) individuals from a third-party agency.
LPM and LPA observed multiple areas of the facility which had bottles of toxic materials which included but not limited to Clorox bleach, paints, a bag of grout, laundry detergent, garden fertilizers, sharp objects, and windshield washer fluid and garden tools accessible to residents. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/03/2023
Section Cited
CCR
80087(g)(1)
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7 | 80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons... & other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients (1) Storage area for... other dangerous weapons shall be locked.
This requirement is not met by: | 1
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7 | This poses an immediate health, safety, or personal rights risk to a peron in care. Licensee agreed and understood cleaning solutions and dangerous weapons need to be locked away and not accessible to clients. Licensee removed observed items and placed them in a locked area during today's visit. |
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14 | Based on inspection, 3 cans of paints, a bag of grout and a bag of morter observed in the front of the house. Antibacterial hand wipes, a gallon of clorox bleach, ajax cleaning solution & other cleaning solutions including unlocked drawer of knives observed in the kitchen. Gardening tools are accessible in backyard. | 8
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14 | Licensee to submit a written and signed statement understanding of this regulation by POC date. |
Type A
03/03/2023
Section Cited
CCR80019(e)(1)
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7 | 80019 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exception....
This requirement is not met by: | 1
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7 | This poses an immediate health, safety, or personal rights risk to a peron in care. Licensee agreed and understood all 3 invididuals are not allowed to be on the premise & left during today's visit. Licensee to submit a written and signed statement understanding of this regulation by POC date. |
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14 | Based on interview and observation, S1 allowed 4 non-fingerprinted individuals on the facility premises. T1-T3 reside in the bedrooms built on facility premise without permit. S1's husband (S2) comes to facility often to supervise the residents while S1 is out of the facility. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/03/2023
Section Cited
CCR
80076(a)(16)
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7 | 80076 Food Service (a)(16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.
This requirement is not met by: | 1
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7 | Licensee agreed and understood disinfectants and cleaning solutions need to be kept seperate from food items. Licensee removed the disinfecting wipes from the kitchen and placed in locked cabinet. Licensee to submit a written and signed statement understanding of this regulation by POC date. |
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14 | Based on inspection of the faclity, a container of Clorox disinfecting wipes 8.5oz was observed in the kitchen counter right next to food (uncovered bowl of cereal). This is an immediate safety risk to the residents in care. | 8
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Type A
03/03/2023
Section Cited
CCR80064(a)(2)(3)
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7 | 80064 Administrator-Qualifications and Duties: (a)(2) Knowledge of the requirements for providing the type of care and supervision needed by clients, including ability to communicate with such clients. (3) Knowledge of and ability to comply with applicable law and regulation. | 1
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7 | Licensee will submit the Department with updated Administration Certification and a written plan to demonstrate Licensee's understanding of Title 22 policies pertaining to care and supervision of residents. Licensee to submit a written and signed statement understanding of this regulation by POC date. |
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14 | This requirement is not met by:
Based on overall outcome of the inspection visit and as a result of multiple deficiencies, Licensee does not have the capacity to provide the care and supervision required to comply with regulations. This is an immediate safety risk to the residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/03/2023
Section Cited
CCR
85076(d)(1)
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7 | 85076 Food Service (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met by: | 1
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7 | This poses an immediate health, safety, or personal rights risk to a peron in care. Licensee agreed and understood the importance of facility having sufficient food supplies and water supply. Licensee will obtain water bottles and replenish food and provide the Department a copy of the receipts. |
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14 | Based on observation, there were only 8 cans of tuna in kitchen cabinets. The food supplies consists of bags of beans, rice, pasta and cup noodles. LPM observed in the fridge a bag of green bell pepper, 2 pcs of tomatoes, 1 bag of celery, 1 pc of cucumber, a lettuce head and 1 eggplant. No water was observed at facility. | 8
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Type A
03/03/2023
Section Cited
CCR80086(a)
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7 | 80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met by: | 1
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7 | This poses an immediate health, safety, or personal rights risk to a peron in care. Licensee agreed and understood the importance of obtaining a building permit and fire clearance. Licensee to submit a written and signed statement understanding of regulation 80086 by POC date. |
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14 | Based on observation and inspection, the licensee built a additional 2 bedrooms outside the physical building floor plan and converted the garage into a bedroom. Licensee verbally admitted to builiding these additional 3 bedrooms after facility was licensed. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/06/2023
Section Cited
CCR
80070(d)
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7 | 80070 Client Records (d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met by: | 1
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7 | This poses a potential health, safety, or personal rights risk to a person in care. Licensee will obtain the proper resident's document for R1-R5 and provide the Department a copy to ensure the resident's files are complete. Licensee to submit a written and signed statement understanding of regulation 80070 by POC date. |
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14 | Based on record review and interview, S1 did not have 5 out of 5 residents files readily available & 3 residents binders which were empty. S1 has LIC 602 for R1 in folder. S1 called residents' social workers if they can send a copy of admission agreements and physician's reports. | 8
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Type B
03/06/2023
Section Cited
CCR80066(a)
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7 | 80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. | 1
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7 | Licensee will prepare a staff file for herself and staff in the facility and provide the Department a copy to ensure the staff files are complete. Licensee to submit a written and signed statement understanding of regulation 80066 by POC date. |
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14 | Based on interviews and record review, S1 does not have file readily available during visit. S1 stated S1's son-in-law (T1) assist with medication. S1 stated that S1's husband (S2) supervised residents when S1 leaves the facility. This poses a potential health, safety, or personal rights risk to a person in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/03/2023
Section Cited
CCR
85065(a)(b)
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7 | 85065 Personnel Requirements (a) In addition to Section 80065, the following shall apply.(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement is not met by: Based on observation and interview, Licensee (S1) reports to work in the morning | 1
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7 | This poses an immediate health, safety, or personal rights risk to a person in care. Licensee will stay at the facility as necessary and hire agency caregiver as temporary solution while hiring additional staff. Licensee will submit necessary documents to associate agency caregivers to the facilty. |
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14 | to fix breakfast between 7am-9am. S1 comes back at 1pm for lunch and leaves, returning back at 5pm for dinner. Facility does not have designated staff supervising residents from 6-6:30pm until 7-8am next morning. Licensee assigned T1 assist with residents medications. T1 is not a designated staff. | 8
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Type B
03/03/2023
Section Cited
CCR85065(c)
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7 | 85065 Personnel Requirements (c) The licensee shall employ support staff as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement is not met by: | 1
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7 | Licensee will ensure the facility's staff will perform office work, cooking, house cleaning, laundry, and maintenane of buildings, equipment and grounds. Licensee will educate residents they need to be supervised if they would like to continue to do their personal tasks. |
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14 | Based on observation and interviews, residents are being required to clean the facility bathrooms and bedrooms, wash their laundry every 10 days and wash bedding sheets unsupervised because there are no designated staff 24/7. This poses an potential health, safety, or personal rights risk to a person in care. | 8
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14 | Licensee to submit a written and signed statement understanding regulation 85065 by POC date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/06/2023
Section Cited
CCR
80068(a)
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7 | 80068 Admission Agreements (a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met by: | 1
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7 | Licensee understood the imporance to keeping resident's records on file at the facility. Licensee will obtain admission agreement for R1 and submit a copy to the Department. Licensee to submit a written and signed statement understanding of this regulation by POC date. |
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14 | Based on interview with S1 and record review, S1 did not have admission agreement for R1. R1 was admitted into the facility on February 16th 2023. This poses a potential health, safety, or personal rights risk to a person in care. | 8
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Type B
03/06/2023
Section Cited
CCR80075(7)(AtoG)
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7 | 80075 Health Related Services (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) ... (B) ...(C) ...(D) ...(E) ....(F) ...(G) Number of refills.
This requirement is not met by: | 1
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7 | This poses a potential health, safety or personal rights risk to a person in care. Licensee understood the importance of keeping medication records for each resident and ensuring each medication pill is accounted for each resident. |
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14 | Based on medication records review and inteviews, S1 did not keep a centrally stored medication for all 5 residents. During medication review, 1 pill (round orange tablet-MYLAN214) in R2's medication box. This medication does not belong to R2. | 8
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14 | Licensee to submit a written and signed statement understanding of this regulation by POC date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/06/2023
Section Cited
CCR
80075(I)
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7 | 80075 Health Related Services (l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. | 1
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7 | Licensee will drop off all medications which are not being order for current residents at CVS Pharmacy to be destory. Licensee to submit a written and signed statement understanding of this regulation by POC date. |
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14 | This requirement is not met by:
During inspection of the centrally stored medication cabinet, a former residents (F1) and (F2) were not destroyed and/or returned to their responsible parties. This poses a potential health, safety, or personal rights risk to a person in care. | 8
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Type B
03/06/2023
Section Cited
CCR80019.1(a)
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7 | 80019.1 Criminal Record Clearence (a) The Department will notify a licensee to... remove...any person...while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice. This requirement is not met by: | 1
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7 | This poses a potential health, safety, or personal rights risk to a person in care. Licensee will ensure S2 will not enter the facility without the exemption. Licensee will follow up with the exemption which she submitted to the Department. |
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14 | Based on review of personnel summary (LIC536), S2 is not associated to this facility as an employee. S1 also stated that S2 requires an exemption and request has been submitted for RCFE facility S1 operates. S2 worked and visited facility with S1 multiple times since the facility began operating. | 8
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14 | Licensee to submit a written and signed statement understanding of this regulation by POC date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/06/2023
Section Cited
CCR
80061(a)
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7 | Reporting Requirements(a) Upon the occurance...a report shall be made to the licensing agency within the agency's next working day (1)(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. | 1
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7 | Licensee/ADM stated that she will adhere to reporting requirements by submitting a written and signed statement of her understanding of reporting requirements by POC date 3/6/23. |
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14 | Based on interview with residents and staff, R1 left the facility on 2/28 for a walk. ADM arrived at the facility to prepare and cook for dinner at 5PM, R1 was observed not home. ADM was worried and called 911because it was raining. Per R1's LIC602 is able leave unassisted. This poses a potiental health, safety or personal rights risk to a person in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/03/2023
Section Cited
CCR
80087(a)
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7 | 80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met by: Based on inspection of the facility, the kitchen cabinets and appliances had splatters of cooking oil, | 1
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7 | This poses an immediate health, safety, or personal rights risk to a person in care. Licensee/Administrator agreed and understood that facilty shall be clean, safe, and sanitary. Licensee will hire a hiring temporary agency staff to assist with cleaning. |
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14 | appeared greasy with yellow and dark spots, floors had dark particles, bathroom filled with grimes and kitchen window covered with dry splatters. The living room occupied with mattress, office supplies and appliances belongs to S1's former office clinic which leaves very limited space for residents to use. | 8
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14 | Licensee will submit pictures of the faciity areas such as bedrooms, bathrooms, living and kitchens by POC date. |
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NARRATIVE |
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32 | LPM and LPA reviewed facility centrally stored medications, staff and resident records, and food supplies.
This visit will be continued at a later date to deliver LIC 809-Ds observed during today's visit both Type A and Type B.
These deficiencies were discussed with Administrator/Licensee Xiuyan Chen. The following deficiencies will be cited under the following regulations:
Type A: 80087(g)(1) Buildings and Grounds, 80019(e)(1) Criminal Record Clearance, 80076(a)(16) Food Service, 80064(1)(2)(3) Administrator Qualification/Duties, 85076(d)(1) Food Services; 80086(a) Alternations to Existing Building or New Facilities, 80019.1(a) Criminal Record Clearance and 80087(a) Building and Grounds.
Type B: 85065(c) Personnel Requirements, 80070(d) Clients Records, 80066(d) Personnel Records, 80068(a) Admission Agreements, 80075(7)(A-G) Health Related Services, 80075(I) Health Related Services and 80061(a) Reporting Requirements.
All Type A deficiencies are due 24 hours before midnight on Friday, March 3rd, 2023.
All Type B deficiencies are due midnight on Monday, March 6th, 2023.
This report was reviewed with Administrator/Licensee Xiuyan Chen. A copy of the report and Appeal Rights were provided. |