Community Care Licensing

Document Has Been Signed on 10/06/2021 09:55 PM - It Cannot Be Edited

FACILITY NAME:	LILY OF THE VALLEY		FACILITY NUMBER:	197606341
ADMINISTRATOR:	NATALIA L. ESPINO		FACILITY TYPE:	740
ADDRESS:	8618 BOTHWELL ROAD		TELEPHONE:	(818) 993-7800
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 4	DATE:	10/06/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:26 PM
MET WITH:	Rudy Espino		TIME COMPLETED:	04:30 PM

SUPERVISORS NAME: Eva Miller LICENSING EVALUATOR NAME: Angelica Arambulo LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Link to Parent Document Below:

FACILITY NAME: LILY OF THE VALLEY	FACILITY NUMBER: 197606341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/14/2021 Section Cited CCR 87211A(1)(a)	1 2 3 4 5 6 7	Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.	1 2 3 4 5 6 7	The administrator shall submit a declaration that he has reviewed the required of this section and shall submit a complete incident on the residents hospitailzations and death. Failure to submit the POC for this citation may lead to civil penalities if not corrected.
	8 9 10 11 12 13 14	This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by record review and administrator admission that he never completes incident reports.	8 9 10 11 12 13 14
Type B 10/14/2021 Section Cited CCR87405(d)(3)	1 2 3 4 5 6 7	Administrator Qualifications: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records.	1 2 3 4 5 6 7	The administrator shall submit a declaration that he has reviewed and understands the required section 87405 on administrator qualifications. The declaration shall be submitted to LPA Arambulo by the due date to clear this citation.
	8 9 10 11 12 13 14	This requirement is not met as evidence by records review and administrator admission to not follow requirements of maintaining records. Such as reporting requirements. each time a resident was hospitalized.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Eva Miller LICENSING EVALUATOR NAME: Angelica Arambulo LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Link to Parent Document Below:

FACILITY NAME: LILY OF THE VALLEY	FACILITY NUMBER: 197606341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/14/2021 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement has not been met as evidence by	1 2 3 4 5 6 7	The administrator shall obtain a copy of the original prescription for the residents antibiotics and submit to LPA along with a declaration that he has reviewed section 87465 regarding medications. This deficiency shall only be cleared once corrections are submitted Failure to do so may be subjected to assessment of civil penalties.
	8 9 10 11 12 13 14	The administrator could not locate the PRN for resident #1 antibiotics. Medication was no longer available.	8 9 10 11 12 13 14
Type B 10/14/2021 Section Cited CCR87508	1 2 3 4 5 6 7	Register of Residents (a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.	1 2 3 4 5 6 7	The administrator shall review section 87508 and submit a declaration that he has read and reviewed and understands this requirement. An LIC9020 shall be submitted to LPA and each time there is a change in census the administrator shall update this form.
	8 9 10 11 12 13 14	This requirement has not been met as evidence by a review of facility documents. The administrator did not know what the register was and did not have any updated documents.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Eva Miller LICENSING EVALUATOR NAME: Angelica Arambulo LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021