565801300-4-22-2021-29-AS-DPEA-C2KNR2-20210430104050

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801300
Report Date: 04/22/2021
Date Signed: 04/22/2021 03:14:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210413092441

FACILITY NAME:	HOME SWEET HOME CARE		FACILITY NUMBER:	565801300
ADMINISTRATOR:	GLORIA P. VALENCIA		FACILITY TYPE:	740
ADDRESS:	7520 VAN BUREN STREET		TELEPHONE:	(805) 659-4427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 5	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Gloria Valencia		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not ensure that medication is inaccessible to residents
Facility staff did not ensure that hazardous items are inaccessible to residents

INVESTIGATION FINDINGS:

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During today's visit Licensing Program Analysts (LPA’s) JoAnn Rosales and Angel Ascencio toured the facility with staff #1 (S1), reviewed resident records and obtained copies of pertinent documents.

Concerns were that facility staff did not ensure that medications and hazardous items were inaccessible to residents. During facility tour on 4/22/21 starting at 9:44 am LPA's observed paint cans, ajax cleanser, carpet cleaner, toilet bowl cleaner, comet cleaner, detergent, dish soap, Raid insect spray, rubbing alcohol, hydrogen peroxide, diaper rash ointment, hammer, scissors, nasal spray, ear wax removal, orajel in an unlocked garage accessible to residents. Starting at 9:49 am LPA's observed 2 bottles of whiskey, ibuprofen, fiber, melatonin, aleve, immodium, meclizine tablets in unlocked laundry room closet accessible to residents. Starting at 9:52 am LPA's observed dish soap, scissors, knife, 2 unknown pills in a pill cup, suppositories, insulin, polymyxin drops in kitchen accessible to residents. Starting at 10:04 am LPA's observed lotion, shampoo & body wash, bars of soap, toilet bowl cleaner, shampoo & conditioner, hair gel, fabuloso cleaner,
Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 29-AS-20210413092441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
	VISIT DATE: 04/22/2021

NARRATIVE

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arm & hammer bathroom cleaner, mouthwash, shower cleaner, multi-purpose cleaner, toothpaste, deodorant, poligrip and anti-itch cream in bathroom accessible to residents. Starting at 10:09 am LPA's observed replens moisturizer, shampoo & body wash in resident #1 (R1)'s bedroom accessible to residents. Starting at 10:11 am LPA's observed lotion, zinc ointment and toothpaste in R2's bedroom accessible to residents. Starting at 10:13 am LPA's observed lotion, chlorthalidone tablets, tylenol, losartan potassium tablets, vicks vapo rub, antibacterial wipes, disinfectant spray, centrum chewables, shampoo, conditioner, calcium, haircolor in an unlocked staff bedroom. Starting at 10:21 am LPA’s observed fabric refresher, acetaminophen, melatonin, scissors, immodium, ricola cough drops, alcohol, lorazepam, lancets in an unlocked staff bedroom. Starting at 10:28 am LPA’s observed retainer cleansing tablets, body wash, shaver spray cleaner and conditioner in bathroom accessible to residents. At 10:36 am LPA’s observed biotene oral rinse and disinfecting wipes in empty bedroom #4 accessible to residents. At 10:38 am LPA’s observed dynashield skin protectant in R3’s bedroom accessible to residents. At 10:40 am LPA’s observed perineal & skin cleanser in R4’s bedroom accessible to residents. Based on LPA’s observations and record review the allegations are deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20210413092441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/23/2021 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care Services. (h)(2) The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff placed medications in a locked medication cabinet and locked refrigerator in garage during facility visit. Administrator stated that they will provide documentation scheduled medication training for staff.
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not comply with the section cited above as resident and staff medications were not kept in a safe locked place which posed an immediate health risk to residents in care.	8 9 10 11 12 13 14
Type A 04/23/2021 Section Cited CCR 87705(f)(1)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff placed items in an inaccessible location during facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87705(f)(1).
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not comply with the section cited above as scissors, hammer and a knives was observed accessible to residents which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210413092441

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/23/2021 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff placed items in an inaccessible location during facility visit. Administrator stated that she will provide documentation of scheduled staff training regarding regulation 87705(f)(2).
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not comply with the section cited above as over the counter medications, vitamins, alcohol and toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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