567609752-3-8-2024-29-AS-TCAA-D36USB-20240308145001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609752
Report Date: 03/07/2024
Date Signed: 03/08/2024 02:50:54 PM

Document Has Been Signed on 03/08/2024 02:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRANDMA EBING'S SENIOR CARE		FACILITY NUMBER:	567609752
ADMINISTRATOR:	SUDARIO, ELLEN		FACILITY TYPE:	740
ADDRESS:	1110 JANETWOOD DR		TELEPHONE:	(805) 307-1612
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	4	CENSUS: 4	DATE:	03/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Cheryl Macht		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required
annual visit. LPA met with licensee Cheryl Macht and discussed the reason for the visit.

LPA toured the physical plant inside and outside to ensure there were no health and safety hazards. The fire extinguisher appeared fully charged and was purchased on 1/27/2024. The smoke and carbon monoxide detectors were tested and functioned properly. The hot water temperature measured 106.1*F.

BEDROOMS: There are three resident rooms. All bedrooms were appropriately furnished, had sufficient lighting and clean linens.

BATHROOMS: There are two bathrooms which were observed to be clean with grab bars and a non-skid mat available. The facility had a generous supply of soap, paper towels and hygiene products.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good

condition. Common seating areas and dining room furniture was observed to be in good condition. The backyard has a covered patio and furniture in good repair. No bodies of water were noted. The side gate was self-latching.

KITCHEN: Appliances appeared to be in operable condition. There was a sufficient supply of perishable and non-perishable food.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient.

(continued on LIC809C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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Document Has Been Signed on 03/08/2024 02:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANDMA EBING'S SENIOR CARE	FACILITY NUMBER: 567609752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(d)(3)

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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response 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 LPA's review of records and medications, the licensee did not comply with the section cited above in one out of one resident's medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee will review regulatory requirements, ensure there are clear physician orders regarding PRN medications, and ensure staff are completing the PRN medication administration log. Licensee will send something in writing to CCL by 3/14/2024 indicating this has been put into practice at the facility.

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) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANDMA EBING'S SENIOR CARE	FACILITY NUMBER: 567609752
	VISIT DATE: 03/07/2024

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(continued from LIC809)

MEDICATIONS: Medications appear to be given as prescribed. The facility form for PRN medications was not completed for a resident who has received PRN medications but is unable to communicate their need for the PRN medication.

RECORDS/INTERVIEWS: Due to the medical condition of residents, interviews were not conducted. LPA interviewed one staff; no concerns noted. Records for staff and residents appear to be complete.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or 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 provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC809 (FAS) - (06/04)

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