565802464-3-27-2024-29-AS-ZCHN-D3RV3L-20240327160456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802464
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:16:27 PM

Document Has Been Signed on 03/27/2024 04:16 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:	EMBRACING SENIORS		FACILITY NUMBER:	565802464
ADMINISTRATOR:	TRUPIANO, JOSEPH		FACILITY TYPE:	740
ADDRESS:	729 MUIRFIELD AVE		TELEPHONE:	(805) 422-8441
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 4	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Regie Dulay, Staff		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Zabel Chochian conducted a Required annual visit to the above facility. Upon arrival LPA met with staff and reason for visit was explained. Staff contacted Administrator Joseph Trupiano by phone. Mr. Trupiano was informed that LPA will be conducting the Annual inspection today. Mr. Tupiano stated that he is unable to be at the facility today due to transportation issues and informed LPA that staff designated will assist LPA with the Annual visit and sign for the report. A tour of the physical plant was conducted with staff at approximately 12:15pm. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: Smoke detectors and Carbon Monoxide detectors were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged with service tag dated 9/13/2023. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Sufficient amounts of supplies for personal hygiene observed. Common Areas: These included the living room and dining area; areas observed clean; furniture in good condition. Surrounding Grounds (Outdoors): There is a shaded area with proper furniture for outdoor use. No bodies of water on the premises. Staff files reviewed approximately 1pm observed to be complete with required documentation such as health screenings, updated first aid/CPR certifications, required annual training and all other pertinent documents required. Staff training records lack start time and information on what material was used for the training. Technical violation issued. (Continue to LIC809C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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)

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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: EMBRACING SENIORS	FACILITY NUMBER: 565802464
	VISIT DATE: 03/27/2024

NARRATIVE

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All resident files reviewed at approximately 1:45pm observed to be complete with required documentation such as admission agreements, updated physician reports, appraisals, and physicians orders for bed rails. Residents' needs and services plan reviewed observed three (3) out of four (4) plans on file were not signed by resident/resident responsible person. Discussed with Licensee, technical violation issued for this violation.
Medications and medication records reviewed from approximately 1:45pm-3pm. Medications observed stored in locked cabinet. Centrally stored logs reviewed observed to be complete/accurate with medications on hand. One out of four residents medications and medication records reviewed revealed that R3 is taking PRN medication and it is indicated by the physician that R3 is unable to clearly communicated and clearly state symptoms for the PRN need. Staff do not have record of contacting physician before providing PRN medication. Tis was discussed with Licensee. Deficiency issued for this violation.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).
Exit interview conducted. Today's reports and appeal rights were discussed with Licensee over the phone. Copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2024 04:16 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(1)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of physician contact made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agreed to audit the residents medication, communicate with physician and provide in-service to staff. Submit proof of steps taken to ensure above POC is met.

Type B

Section Cited

CCR

87465(d)(2)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of contacts made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agreed to audit the residents medication, communicate with physician and develop instructions foe staff to follow to ensure compliance with above. Licensee agreed to provide in-service to staff. Submit proof of steps taken to ensure above POC is met.

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: Zabel Chochian	TELEPHONE: (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)

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Document Has Been Signed on 03/27/2024 04:16 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(d)

Other Provisions

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Facility emergency disaster plan was not reviewed/updated. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agreed to review facility emergency plan and update as necessary and submit copy to CCL. Licensee shall ensure that the plan is reviewed annual and signed. Submit statement of understanding above section cited.

Type B

Section Cited

CCR

87609(b)(4)

Allowable Health Conditions and the Use of Home Health Agencies

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the licensee did not comply with the section cited above. R1 is receiving home health services in the facility. No agreement between licensee and home health agency observed on file. This pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agreed to review section sited and submit in writting how he will ensure future complaince.

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: Zabel Chochian	TELEPHONE: (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)

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