561703573-8-29-2023-29-AS-ECOZ-CV73FF-20230829181237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703573
Report Date: 08/29/2023
Date Signed: 08/29/2023 06:14:17 PM

Document Has Been Signed on 08/29/2023 06:14 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 43	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Fe Higgins		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:14 a.m. Licensing Program Analysts (LPAs) Esther Cortez and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. The LPAs were greeted by Licensee Fe Higgins and informed them of the reason for the visit. Licensee Fe Higgins asked the LPAs if they could come back at a later time as she and only one other staff were present and would not be able to assist us. The LPAs advised the administrator if it was possible for them to conduct interviews in the meantime, which at the time two staff arrived at the facility. At 10:35 a.m. the LPAs conducted a tour of the physical plant with Licensee Fe to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The LPAs observed fire extinguishers throughout the facility, which were fully charged and last serviced 05/08/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPAs observed all required postings in the hallways leading to the living area. The LPAs discussed annual fees with Licensee Fe. The Licensee stated that the fees had just been paid and mailed out and gave a copy of the check to the LPAs. Kitchen: During the facility tour at 10:35 a.m., the kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPAs observed the following: an orange and tomato with mold, one cottage cheese container with fruit not properly labeled, one cottage cheese container with sauce not properly labeled, one open jelly container with mold on the lid, one southwest style ranch dressing expired on 6/30/19, one sesame ginger avocado oil expired on 8/31/19, one Italian avocado oil expired on 8/27/19, one ramen broth expired on 10/30/22 inside the fridge. The LPAs also observed salad plates that were prepared for lunch for residents left uncovered. Lastly, the LPAs observed cleaning supplies stored underneath the sink to the left in an open space inside the kitchen. Report will continue on LIC809-C..

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 08/29/2023 06:14 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, during plant tour, the licensee did not comply with the section cited above detergent was present present in a resident's bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Licensee will read and submit statement of understanding of Regulation 87309 and send to CCL by 09/08/2023.

Type A

Section Cited

CCR

87555(b)(25)

General Food Service Requirements

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during plant tour, the licensee did not comply with the section cited above as cleaning supplies are stored inside the kitchen next to the food/food preparation area, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	The Licensee locked all cleaning supplies away from the kitchen at the time of visit. Licensee will read and submit statement of understanding of Regulation 87555 and send to CCL by 09/08/2023.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(a)(2)(A)

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during the polant tour, the licensee did not comply with the section cited above as one (1) resident's bathroom wall and toilet were stained and dirty, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	The Licensee has nagreed to clean all residents restrooms and send to CCL by poc due date.

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during plant tour, the licensee did not comply with the section cited above as resident's bedroom was observed with dirt and liquid on the floor, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	The Licensee had staff clean, sweep, and mop room at the time of visit. POC has been met.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as all staff's 1st aid/cpr certification expired in May 2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	The Licensee will have all staff recertified in 1st aid/cpr by poc due date.

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as five (5) out of five (5) resident files are missing the pre-appraisal, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	The Licensee will complete a pre-appraissal for all residents and submit copies to CCL by poc due date.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 06:14 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as, three (3) out of five (5) resident files are either missing admissions agreement or not not filled out and signed by resident, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licnesee will have admissions agreement for all residents filled out and submit proof to CCL by poc due date.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during plant tour, the licensee did not comply with the section cited above as food in pantry such as cake mix, condiments, grits, coffee, and pasta were found to be expired, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2023
	Plan of Correction
1 2 3 4	Licensee disposed of expired foods at the time of the visit. POC has been met.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during medication audit, the licensee did not comply with the section cited above as facility staff is currently writing information on medication bottle caps with a marker, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2023
	Plan of Correction
1 2 3 4	Licensee willl read and submit statement of understanding of Regulation 87465 and submit to CCL by poc due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview conducted, the licensee did not comply with the section cited above as the facility has not conducted an emergency drill witihin the last 90 days and has not been conducting drills quarterly, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Licensee will conduct emergency drill with facility staff and submit proof to CCL by poc due date.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 06:14 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(A-F)

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review, the licensee did not comply with the section cited above as the facility is not filling out a centrally stored medication and destruction record for all residents, which poses a potential health and safety to residents in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Licensee will have a centrally stored medication ad destruction log for each resident and submit proof to CCL by poc due date.

Section Cited


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

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 08/29/2023

NARRATIVE

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At 11:31 a.m. the LPAs observed perishable items in poor condition which were expired - 6 Turkey Brine bags (exp.10/20/22), 1 red enchilada sauce can (exp. 3/20/18), 3 sunflower quick grits (exp. 7/15/21), 2 Jim Dandy quick grits boxes (exp. 5/10/21), 2 corn muffin mix boxes (exp.11/2/19), 6 Graham cracker crumbs boxes (exp. 5/4/21), 1 bold and roasty coffee bag (exp.12/16/20), 1 oatmeal bag (exp.3/30/23), 1 yellow cake mix box (exp. 6/12/18), 2 Funfetti cake mix boxes (exp.11/28/22), 1 Pillsbury cookie mix (exp. 1/6/18), 1 butter golden cake mix box (exp.7/2/17), 2 white cake mix (exp. 8/19/18), 1 jiffy corn muffin mix (exp.11/7/20), 3 apple cider vinegars (exp. 2/23), 13 holiday cookies mix boxes (exp.8/3/20), 3 macaroni & cheese boxes (exp.6/3/22), 5 hot sauce bottles (exp.7/10/23), 1 taco sauce (exp.12/6/22).

Bedrooms: During today’s visit, the LPA observed four (4) randomly selected resident units. The resident bedrooms were furnished with at least one chair, nightstand and sufficient lighting for each resident. At 11:09 a,m. the LPAs observed a residents bed in bedroom #7 with stained linen and pillow cases, the floor was observed wet and stained, and the room only had 1 chest of drawers for one of the two residents. Upon observation, staff came in to sweep and mop the floor. At 11:11 a.m. the LPAs observed a bag of clothing detergent in room #7.

Bathrooms: The LPA observed bathrooms and shower rooms, properly supplied, and had functional fixtures. The LPA observed grab bars and non-skid mats in the shower rooms. At 11:05 a.m. one (1) bathroom was observed to require cleaning as the toilet and walls were stained. At 11:07 a.m., hot water temperature was measured in a resident’s restrooms at 108.3 degrees Fahrenheit.

Common Areas: These included the dining, living areas, front and back yards. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The LPAs observed books and magazines in the living room, however facility staff are not currently encouraging residents to participate in activities.

Surrounding Grounds (Outdoors): The LPA observed outdoor furniture, with a covered shaded area for residents.

Infection Control: The facility was observed to be unkept and unsanitary, and not properly disinfecting floors and surface areas.
Report will continue on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

Page: 56 of 57

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 08/29/2023

NARRATIVE

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Record Review: At 02:09 p.m. a review of resident’s files was initiated. LPAs reviewed five (5) of forty-seven (47) resident files. Out of the five files reviewed, the LPAs identified that three out of five residents (R1, R3, R4) do not have an appraisal/needs and services plan (LIC603). Two residents (R2, R4) do not have a physician’s report LIC602. Two residents (R2, R3) admissions agreements are not filled out and signed by residents. One resident (R5) admissions agreement is not signed by resident. Two residents (R4, R5) do not have personal rights agreements LIC 613. Three residents (R2, R4, R5) do not have medical consent forms on file. One resident (R4) does not have negative Tuberculosis results on file. Resident #3 (R3) identification and emergency form (LIC 601), LIC 603, LIC 602 are from the Golden Ventura CRT facility. Lastly, five out of five residents do not have pre-appraisals on file.
At 3:00 p.m. a review of staff files was initiated. Licensee was able to only present two (S1, S2) staff files for review., The following was noted during the staff file review: First aid/CPR certification was expired, and no annual training was on file for both staff. S1 did not have an LIC501, and negative tuberculosis results on file. The Licensee was not able to provide record of the last emergency drill conducted.

Medication Audit: A medication audit was initiated at 3:15 p.m.; medications are centrally stored and locked in a medication room; medications are labeled and checked for expiration dates. The LPAs were unable to conduct a medication audit due to facility unable to provide the centrally stored medications and destruction record log.

Interviews: During today’s visit, the LPAs conducted three (3) resident interviews.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee Fe Higgins.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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