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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802464
Report Date: 03/27/2024
Date Signed: 03/27/2024 12:15:43 PM


Document Has Been Signed on 03/27/2024 12:15 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:EMBRACING SENIORSFACILITY NUMBER:
565802464
ADMINISTRATOR:TRUPIANO, JOSEPHFACILITY TYPE:
740
ADDRESS:729 MUIRFIELD AVETELEPHONE:
(805) 422-8441
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
03/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Regie Dulay, StaffTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC # 29-AS-20230523101459). LPA met with staff Regie Dulay. Staff contacted Licensee/Administrator and LPA reviewed the report with Licensee. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.

The facility failed to seek medical attention in a timely manner for Resident #1 (R1). During interviews, the staff and administrator acknowledged R1’s pressure injuries progressively worsened, and they did not seek medical attention. Staff and administrator continuously stated the prescribed ointment was not received; however, staff and administrator failed to seek medical attention and inform a medical professional that the discharge care treatment was not being done.

The facility failed to report R1’s fall incident in the bathroom to Community Care Licensing (CCL). The fall resulted in R1 having bruises on forehead and lower extremities. It was noted in the 05/22/2023, Adventist Health Simi Valley medical records, that R1 had several areas of bruising to the forehead and lower extremities. The evaluation noted the bruising was consistent with a recent fall.

The 05/12/2023 Special Incident Report (SIR) noting a “rash” to R1’s left shoulder and hip requiring a doctor visit, diagnosed as pressure injuries, was dated 05/25/2023, more than 7 days after the incident date. There is no evidence or confirmation that the SIR was submitted to CCL. R1’s hospice notification, dated 05/25/2023, was also not received by CCL.

R1’s Physician Report, dated 02/27/2023, lists R1 as not on hospice and not able to perform any activities of daily living, which is considered a prohibited health condition. R1 was placed on hospice care on 05/24/2023. Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
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 3


Document Has Been Signed on 03/27/2024 12:15 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: EMBRACING SENIORS
FACILITY NUMBER: 565802464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
CCR
87465(a)(1)

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(a) A plan for incidental medical and dental care shall be developed by facility. The plan shall encourage routine medical and dental care.... (1) The licensee shall arrange.....for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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The licensee agreed to submit a plan describing how they will ensure residents will receive timely medical care. Submit proof to CCL by due date.
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Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee did not seek medical attention when R1’s pressure injuries progressively worsened, which posed an immediate health and safety risk to residents in care.
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Type A
03/28/2024
Section Cited
CCR87615(a)(5)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified....(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by:
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The licensee agreed to submit a memo of understanding that you have read Prohibited Health Conditions and Exceptions For Health Conditions. Submit proof to CCL by due date.
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Based on records review, the licensee did not comply with the section cited above. The licensee retained R1 who depended on others to perform all activities of daily living, which posed an immediate health and safety risk to residents in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/27/2024 12:15 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: EMBRACING SENIORS
FACILITY NUMBER: 565802464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2024
Section Cited
CCR
87211(a)(1)(B)

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(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... within seven days of the occurrence of any of the events specified in.....(B) Any serious injury....while the resident is under facility supervision. This requirement is not met as evidenced by:
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The licensee agreed to submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by due date.
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Based on interviews and records review, licensee did not comply with the section cited above. No evidence or confirmation that the licensee submitted the 5/12/2023 SIR, dated 05/25/2023, to CCL. Licensee did not submit an SIR for R1’s fall , which posed a potential health and safety risk to residents in care.
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Type B
04/03/2024
Section Cited
CCR87632(d)(2)

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(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver....... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally Ill resident.....
This requirement is not met as evidenced by:
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The licensee agreed to submit a plan describing how you will ensure notification of the initiation of hospice care services is met within the required time frame. Submit proof to CCL by due date.
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Based on records review, the licensee did not comply with the section cited above. There is no evidence/confirmation that the licensee submitted a notification for R1’s 05/24/2023 initiation of hospice care services, which posed a potential health and safety risk to residents in care.
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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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3