Community Care Licensing

Document Has Been Signed on 10/24/2023 12:00 PM - It Cannot Be Edited

FACILITY NAME:	DE UN AMOR		FACILITY NUMBER:	445201621
ADMINISTRATOR:	FLETES, MARICELA		FACILITY TYPE:	740
ADDRESS:	460 EUREKA CANYON ROAD		TELEPHONE:	(831) 728-0303
CITY:	CORRALITOS	STATE: CA	ZIP CODE:	95076
CAPACITY: 25		CENSUS: 21	DATE:	10/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Saaj Kaiyom		TIME COMPLETED:	05:45 PM

SUPERVISORS NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

FACILITY NAME: DE UN AMOR	FACILITY NUMBER: 445201621
	VISIT DATE: 10/06/2023

Document is an Amendment of Original Document on 10/24/2023 09:02 AM

Link to Parent Document Below:

FACILITY NAME: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Type A

Section Cited

CCR

87465(h)(1)B)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by: Licensee did not ensure that residents R1 and R2 did not have prescription medications unsecured in their resident living units, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that residents R1 and R2 did not have prescription medications unsecured in their resident living units, which poses an immediate safety risk to residents in care. **Amended on 10/24/2023 to edit the Deficient Practice Statement **
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a Plan of Correction by POC date to ensure that there are no unsecured medications in resident living units and staff are trained to prevent medications from being left unsecured in resident living units. Licensee agrees to submit copies of training records to CCL once training is completed.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Licensee did not ensure that residents R3 and R4 did not have unsecured sharp objects in their bedrooms, which poses an immediate safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that residents R3 and R4 did not have unsecured sharp objects in their bedrooms, which poses an immediate safety risk to residents in care. **Amended on 10/24/2023 to edit the Deficient Practice Statement **
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a Plan of Correction by POC date to ensure that there are no unsecured sharp objects in resident living units and staff are trained to prevent sharp objects from being stored in resident living units. Licensee shall submit training records to CCL once training is completed.

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Document is an Amendment of Original Document on 10/24/2023 09:07 AM

Link to Parent Document Below:

FACILITY NAME: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Type B

Section Cited

CCR

87465(e)(1-4)

87465 Incidental Medical and Dental Care (e)(1-4): For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2)The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. This requirement is not met as evidenced by: Licensee did not ensure that R1 had a medication with a prescription label, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that R1 had a medication with a prescription label, which poses a potential safety risk to residents in care. **Amended on 10/24/2023 to edit the Deficient Practice Statement **
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to audit all resident medications and ensure that all medications have a prescription label by POC date. Licensee agrees to submit photographic evidence of R1's medication with a prescription label and a statement of completion that all medications have been reviewed and have medication labels by POC date.

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023

Document is an Amendment of Original Document on 10/24/2023 09:08 AM

Link to Parent Document Below:

FACILITY NAME: DE UN AMOR	FACILITY NUMBER: 445201621
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements – General. This requirement is not met as evidenced by: Licensee did not ensure that staff S1 had a LIC503 Health Screening Form in S1's staff record, which poses a potential safety risk to residents in care.
	Deficient Practice Statement
1 2 3 4	Licensee did not ensure that staff S1 had a LIC503 Health Screening Form in S1's staff record, which poses a potential safety risk to residents in care. ** Amended on 10/24/2023 to edit the Deficient Practice Statement **
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that all staff have LIC503 Health Screening forms in their staff records and submit a statement of completion and a copy of S1's completed Health Screening Form by POC date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sarah Yip LICENSING EVALUATOR NAME: David Marrufo LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023