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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801398
Report Date: 09/27/2021
Date Signed: 09/27/2021 06:16:35 PM

Document Has Been Signed on 09/27/2021 06:16 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:CALIFORNIA CARE RCFE-BAXTERFACILITY NUMBER:
565801398
ADMINISTRATOR:MANIJEH MARY REZAEIFACILITY TYPE:
740
ADDRESS:283 BAXTER STREETTELEPHONE:
(805) 498-5685
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY: 6CENSUS: 6DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:TIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs), KaSandra Lopez and Martha Guzman Chavez conducted an unannounced visit to California Care RCFE-Baxter to conduct a Required 1-Year Annual Inspection with focus on Infection Control beginning at 11:14 AM. LPA’s were greeted and screened at the door by caregiver, Russell Lapiad. LPA’s met with Licensee Representative Reza Rezaei and the reason for the visit was explained. Licensee Representative Manijeh Rezaei arrived at the facility at 12:10 PM.

Before conducting the physical plant inspection, the LPAs discussed with Reza Rezaei the pending sale of the property and change of ownership. Mr. Rezaei stated the property is currently in escrow with the pending applicant and scheduled to close on approximately 10/29/2021. The LPAs showed Mr. Rezaei a copy of the License Agreement signed on 08/15/2021 by the pending applicants and signed by Manijeh Rezaei on 08/17/2021. The document states both parties agree on the terms and conditions hereby set in the agreement and the BPA to be entered in 30 days prior to the close of escrow. Mr. Rezaei stated he was not aware of terms of this agreement as his wife signed the document but is aware the facility license is not transferable. Mr. Rezaei stated he is aware, he as the licensee representative cannot give the applicant or any other entity rights to use their RCFE license. He stated he will be in charge of the facility until the new license is approved. When Manijeh Rezaei arrived, she was asked about the agreement she signed. Mrs. Rezaei stated it was her signature on the document but she did not recall signing this agreement and was not aware of the terms. At 1:20 PM. LPA Lopez spoke with the licensee's broker. They stated the agreement was not official and they were waiting to see if the applicant would be approved for the property loan. The broker stated they would draft a new document stating this agreement is null and void by the end of the day. The LPA is requesting a copy of this document and any new agreement drafted. LPAs also discussed with Mr. Rezaei that per H&S §1569.191 The licensee shall provide written notice to the department and to each resident or his or her legal representative of the licensee's intent to sell the facility at least 30 days prior to the transfer of the property or business, or at the time that a bona fide offer is made, whichever period is longer. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 09/27/2021 06:16 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/27/2021 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA CARE RCFE-BAXTER
FACILITY NUMBER: 565801398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as the water temperature in both resident bathrooms measured at 127.4 degrees F. which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/05/2021
Plan of Correction
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Staff turned down the water heater during the inspection. The licensee shall complete a 5 day water temperature log which indicates the water temperature is within the required range of 105-120 degrees and submit proof the CCL by 10/05/2021.
Type A
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there is a water fountain in the back yard which had at least five inches of water in it which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/27/2021
Plan of Correction
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The administrator removed the water from the fountain during the inspection. Plan of correction cleared. This is a zero tolerance violation and civil penalties will be assessed.
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
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 09/27/2021 06:16 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/27/2021 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA CARE RCFE-BAXTER
FACILITY NUMBER: 565801398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as laundry detergent, clorox spray, ajax, and galss cleaner were accessible to residents with dementia which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/27/2021
Plan of Correction
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The items were secured the during the inspection. Plan of correction cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/27/2021 06:16 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/27/2021 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA CARE RCFE-BAXTER
FACILITY NUMBER: 565801398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above as the fire extingusher is fully charged but last serviced on 8/18/2020, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2021
Plan of Correction
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The administrator shall submit proof the fire extinguisher has been serviced to CCL by 10/05/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


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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: CALIFORNIA CARE RCFE-BAXTER
FACILITY NUMBER: 565801398
VISIT DATE: 09/27/2021
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Mr. Rezaei was also advised per H&S §1569.682, the licensee shall give the residents and their legal representative and/or responsible party at least a 60 day notice regarding the facility closure and change of ownership with the required information in the notice per the H&S code. Within 5 days of issuing the notices, the licensee must also submit copies of the notices to CCL.

LPA’s 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.

LPA’s along with Mr. Rezaei, initiated a tour at 11:50 AM and the following was observed:

There is a central entry point designated for universal screening for visitors by the entrance. At 11:55 AM, smoke detectors and carbon monoxide detector were tested in all rooms and functioned properly. At 11:58 AM, LPA’s observed a fire extinguisher in the kitchen last charged on 08/18/2020. Facility’s main temperature displayed at 73 degrees Fahrenheit. LPA’s observed washing hands signs posted throughout facility and resident bathrooms. Facility does not have 30-day PPE. LPA’s observed a sufficient amount of emergency food and water stored in the garage. At 11:50 AM the LPAs observed detergent pods in the laundry room area accessible to residents. OUTDOOR SPACE: LPA’s observed the outdoor space to have shaded area with a tables and chairs for resident use. There is one gate on the side of the house that is self-latching with a clear passageway in case of an emergency. LPA’s observed water fountain with water accessible to residents. Licensee corrected during visit. KITCHEN: LPA’s observed the kitchen/dining area to be clean. Knives are stored in a locked drawer under the kitchen island. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. First-Aid Kit and Manual were observed to be complete. Medications are locked in a cabinet in the kitchen inaccessible to residents. At 11:55 cleaning supplies of Clorox cleaner, Ajax, and glass cleaner in an unlocked cabinet under the sink. BEDROOMS: LPA’s observed the resident bedrooms, which were furnished appropriately. Observed inside each room was a bed with clean linens, a night stand, and adequate lighting. RESTROOMS: LPA’s observed the restrooms to be clean, sanitary and in operating condition with grab bars and non-skid mats. There are two (2) bathrooms for resident use. Bathrooms were measured for hot water, both bathrooms measured at 127.4 degrees Fahrenheit. RECORDS: Resident records were reviewed and five out of six residents have a dementia diagnosis.

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 was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
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