561703785-7-6-2023-29-AS-MARO-CTGTWY-20230706150619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703785
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:06:52 PM

Document Has Been Signed on 07/06/2023 03:06 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:	LAIGO-ZANDERS HOME FOR THE ELDERLY II		FACILITY NUMBER:	561703785
ADMINISTRATOR:	NORMA L. ZANDERS		FACILITY TYPE:	740
ADDRESS:	3190 E. ELMORE STREET		TELEPHONE:	(805) 527-3007
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 6	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Norma Zanders		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. The last annual conducted at this facility was on 07/06/2022. Upon arrival, the LPA was greeted at the door by staff. The Administrator, Norma Zanders arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 9:30 a.m. The LPA observed two residents having breakfast at the dining table. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:35 a.m., the hot water temperature was measured in the kitchen at 113.7 degrees Fahrenheit. Cleaning supplies were observed locked and inaccessible under the kitchen sink.

COMMON AREAS: At the time of the visit, the living room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. At 9:45 a.m., the fire extinguisher was observed to be last charged on 09/14/2021. Administrator stated they were waiting on the service technician to recharge. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space.

The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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 07/06/2023 03:06 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: LAIGO-ZANDERS HOME FOR THE ELDERLY II	FACILITY NUMBER: 561703785
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as fire extinguisher was last charged on September 2021, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	The Administrator will have fire extinguisher recharged and show proof to CCL by 07/10/2023.

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: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAIGO-ZANDERS HOME FOR THE ELDERLY II	FACILITY NUMBER: 561703785
	VISIT DATE: 07/06/2023

NARRATIVE

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Report Continued from LIC C809...

The laundry room is located in the garage, which is kept locked at all times. Cleaning supplies and disinfectants are also kept locked inside the garage. Emergency water and food was observed in good condition at the time of the visit. The last fire drill was conducted in March 2023.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) designated resident rooms. Two (2) bedrooms are private, and two (2) bedrooms are shared. The facility has staff bedrooms and sections upstairs in the second floor which is maintained inaccessible to residents at all times.

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 113.5 degrees Fahrenheit at 9:40 a.m.; and the second bathroom measured at 113.9 degrees Fahrenheit at 9:42 a.m.

RECORDS: Records review began at 9:58 a.m.; six (6) resident records were reviewed for the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, appraisals, and current needs and services plan. Resident #1’s (R1’s) LIC 602A indicated R1 has no capacity for self-care and is not on hospice. Administrator stated R1 was no longer on hospice and was able to do certain activities of daily living (ADL’s) on their own. R1’s Primary Care Physician (PCP) faxed an updated LIC 602A indicating R1 has capacity for self-care during the time of visit. All resident files are now in order.

The LPA reviewed four (4) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files and training is in order.

The LPA also audited the current Administrator’s file, and it was in order.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAIGO-ZANDERS HOME FOR THE ELDERLY II	FACILITY NUMBER: 561703785
	VISIT DATE: 07/06/2023

NARRATIVE

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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at 1:20 p.m. The medications are centrally stored and locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. No errors found during medication audit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID - 19. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights was provided to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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