565802468-11-9-2023-29-AS-MARO-CXETW2-20231109140450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802468
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:05:04 PM

Document Has Been Signed on 11/09/2023 02:05 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:	AMERICA'S CARE MANOR		FACILITY NUMBER:	565802468
ADMINISTRATOR:	MARIA D. CALLES		FACILITY TYPE:	740
ADDRESS:	5794 KATHERINE STREET		TELEPHONE:	(818) 448-8641
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 6	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Calles		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 10/27/2022. When the LPA arrived, there was one (1) staff and six (6) residents present. Upon arrival, LPA met with Administrator, Maria Calles and the reason for the visit was explained. Entrance interview conducted.

At 8:22 a.m., the LPA along with the Administrator 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 8:33 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels. The knives and sharps stored in a box locked under the kitchen sink. At 8:35 a.m., the water temperature was measured at 108.5 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed six (6) residents having breakfast during the inspection. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed fully charged and last serviced on 05/03/2023. The LPA observed activities available and accessible to residents in care. Cameras were observed in the common areas. The last emergency drill was conducted on 09/15/2023. (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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
	VISIT DATE: 11/09/2023

NARRATIVE

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(Report Continued on LIC 809C...)

GARAGE/BACKYARD: The washer and dryer are in the garage. The garage is kept locked at all times. The facility has emergency food and water which was observed to be in good condition. Cleaning supplies and toxins were observed locked and inaccessible to residents in care. The facility has at least a 30-day supply of Personal Protection Equipment (PPE). The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There are two (2) gates with self-closing mechanisms. No bodies of water were noted at the time of the visit.

BEDROOMS: There are four (4) resident bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The LPA observed a closet in the hallway with extra towels and linens.

RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in bedroom #4. 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; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; the first bathroom measured 101.4 degrees Fahrenheit at 8:29 a.m.; and the second bathroom measured 105.6 degrees Fahrenheit. The Administrator had water adjusted at the time of the visit.

RECORDS: Records review began at 9:21 a.m.; six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.

At 9:22 a.m., review of Resident #1’s (R1’s) Admissions Agreement (AA) noted a few sections where R1’s Power of Attorney (POA) needs to initial. The Administrator will have R1’s POA review AA.

(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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
	VISIT DATE: 11/09/2023

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(Report Continued from LIC 809C...)

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

The current Administrator’s file was also reviewed, and it was in order.

At the time of the visit, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance.

MEDICATIONS: Medications review began at approximately 11:30 a.m.; medications are centrally stored and locked in a cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. At 11:38 a.m., during the medication review, one discrepancy was noted as Resident #2’s (R2’s) medication Cetirizine CHL 10 mg tabs had one (1) extra bubble popped open and one (1) pill was missing. The Administrator was unable to say why there was a missing pill.

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 issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/09/2023 02:05 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: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

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 record review and LPA observation, the licensee did not comply with the section cited above as R2's medication Citirizine HCL 10 mg tabs had one (1) missing pill, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	The Administrtaor has agreed to have an in-house training on administering medications and submit to CCL by 11/17/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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