565800686-7-26-2024-29-AS-MARO-D7JTKJ-20240726144801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800686
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:48:13 PM

Document Has Been Signed on 07/26/2024 02:48 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:	ST. PAUL'S HOME CARE II		FACILITY NUMBER:	565800686
ADMINISTRATOR:	NORMA ZANDERS		FACILITY TYPE:	740
ADDRESS:	1431 CROCKER STREET		TELEPHONE:	(805) 638-6004
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 6	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Norma Zanders / Paul Laigo		TIME COMPLETED:	03:00 PM

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Licensing Program Analysts (LPAs) Martha Arroyo and Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. Upon arrival, there were two (2) staff and six (6) residents present. The LPAs met with staff and the reason for the visit was explained. The Administrator, Norma Zanders and the Licensee, Paul Laigo arrived at 9:35 a.m. Entrance interview conducted.

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

KITCHEN: The LPA inspected the kitchen/food service area at 9:37 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 108 degrees Fahrenheit at 9:41 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 10:00 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 09/11/2023. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 07/07/2024. Activities were observed in the common areas. LPAs observed working auditory alarms 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: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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: ST. PAUL'S HOME CARE II	FACILITY NUMBER: 565800686
	VISIT DATE: 07/26/2024

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Report Continued from LIC 809...

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 109 degrees Fahrenheit at 9:44 a.m.; and the second bathroom measured at 119.4 degrees Fahrenheit at 9:49 a.m.

BEDROOMS: There are 6 (six) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage is maintained locked at all times. There is a washer and dryer on premises. Laundry detergent was observed in a locked cabinet above the washer and dryer. LPAs observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed two (2) self-latching gates. There were no bodies of water noted at the time of the visit.

RECORDS: LPAs reviewed Resident Records at 10:09 a.m. and Personnel Records at 11:18 a.m.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

At 10:45 a.m., record review revealed that four (4) out of six (6) residents are currently on Hospice; however, the facility does not have a hospice waiver. The Administrator stated they will be submitting a hospice waiver increase to the department.

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: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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: ST. PAUL'S HOME CARE II	FACILITY NUMBER: 565800686
	VISIT DATE: 07/26/2024

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Report Continued from LIC 809C...

Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

MEDICATIONS: Medications review began at approximately 12:40 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates.

At 1:00 p.m., medication review revealed that Resident #1 (R1) has eleven (11) routine medications; however, two (2) medications had not been administered in the A.M.; and one (1) medication was missing one (1) tablet that was not accounted for.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/26/2024 02:48 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: ST. PAUL'S HOME CARE II	FACILITY NUMBER: 565800686
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review and LPAs observation, the licensee did not comply with the section cited above as three (3) out of eleven (11) medications for R1 are not being given according to the physician's directions, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	The Licensee will audit medications and review Regulation 87465 Incidental Medical and Dental Care and submit a statement of understanding to CCL no later than 08/09/2024.

Type B

Section Cited

CCR

87633(a)(1)

Hospice Care for Terminally Ill Residents

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above as the facility does not have a hospice waiver approved by the department and four (4) out of six (6) residents are currently on hospice, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	The Licensee will review Regulation 87633 Hospice Care of Terminally Ill Residents and submit a hospice care waiver to the department no later 08/09/2024.

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: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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