Community Care Licensing

Document Has Been Signed on 11/18/2024 03:26 PM - It Cannot Be Edited

FACILITY NAME:	CARRILLO MANOR		FACILITY NUMBER:	197607305
ADMINISTRATOR/ DIRECTOR:	ROWENA MARANTAL-CARRILLO		FACILITY TYPE:	740
ADDRESS:	14006 SYLVANWOOD AVE.		TELEPHONE:	(213) 281-1439
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 6		CENSUS: 4	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:23 AM
MET WITH:	Licensee Rowena Marantal Carrillo		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

SUPERVISORS NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024

FACILITY NAME: CARRILLO MANOR	FACILITY NUMBER: 197607305
	VISIT DATE: 11/18/2024

Link to Parent Document Below:

FACILITY NAME: CARRILLO MANOR	FACILITY NUMBER: 197607305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA observed with Administrator Carrillo in the kitchen in the unlocked cabinets above the fridge a (3) sprag cans Thompson's WaterSeal (water proof exterior surfaces), Zep Heavy Duty Foaming (Degreaser), Resolve (Carpet Cleaner). Backyard LPA observed with Administrator Carrillo (2) bottles Ortho and Spectracide (Insect Killer) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Adminstrator removed the disinfectants, and cleaning solutions and placed them in a secure location. Administrator to provide In-Service training for all staff on cleaning solutions being inaccessible to clients. The In-Service Training will include list of attendees’ names and attendees’ signatures. Licensee will provide proof of In-Service Training to licensee by POC Due Date

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA observed with staff #1 (S1) in the office area (3) individual pills in an unlocked drawer located in the office area. In the unlocked metal file cabinet in the hallway LPA observed with S1 an Advion Cockroach Insecticide 1.06 oz (30g). LPA observed with Administrator Carrillo in a plastic container medication in the unlocked end table in Room 4, which was unlocked and as accessible to residents. The medication observed in a plastic container was Haloperidol Injection, BD Intega Syringe 25G/3ml, Ipratropium Bromide and Albuterol Sulfate Solution, Hyosyne 0.125, and Eliquis which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that all medication is kept safe and in a locked place that is not accessible to person other than employees responsible. Licensee will provide in-service training for all staff on the ensuring medication is secured. The in-service training will include list of attendees names and attendees signatures. Licensee will provide proof of in-service training to CCL by POC Due Date.

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024

Link to Parent Document Below:

FACILITY NAME: CARRILLO MANOR	FACILITY NUMBER: 197607305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

Type A

Section Cited

CCR

87465(c)(2)

(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 observation , the licensee did not comply with the section cited above During medication review of resident #1 (R1) and R2 it was observed medication was not given as prescribed by the physician for the month of November 2024. R1's AM Medication - Midodrine Hcl 5mg (Take 1 tablet by mouth daily for Hypertension) were still in the bubble 11/1/24 and 11/2/24 despite been marked on the Nov 2024 medication sheet as given. R1's Medication - Tramadol 50mg ( Take 1 tablet by mouth prior to movement or may give every 6hrs for pain) on the Nov 2024 medication sheet it was initialed by staff as being given 11/1/2024 -11/18/24 despite only (15) pills being removed from the bubble pack. R1's Medication - Haloperidol 5mg (Take 1 tablet by mouth every 6hrs as needed) on the Nov 2024 medication sheet it was initialed by staff as being given 11/1/2024 -11/18/24 despite only (11) pills being removed from the bubble pack. R1's Bedtime Medication- Senna 8.6 mg (Take 1 tablet by mouth at bedtime) on the Nov 2024 medication sheet for 11/18 was already intialed by staff as being given despite still being in the bubble pack. R1's Bedtime Medication - Mirtazapine 7.5 mg( Take 1 tablet by mouth at bedtime) on the Nov 2024 medication sheet for 11/18 was already initialed by staff as being given despite still being in the bubble pack. R2's AM Medication (Take 1 tablet for Hypertension) on the Nov 2024 medication sheet for 11/18 was initialed by staff as being given despite still being in the bubble pack which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Adminstrator will provide LPA with thefollowing documents in-service training for all staff on medication, and that R1's and R2's physician was notified by POC Due Date.

Section Cited

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

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024

Link to Parent Document Below:

FACILITY NAME: CARRILLO MANOR	FACILITY NUMBER: 197607305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

Type B

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above In the backyard LPA observed with Administrator Carrillo a mattress with metal frame in the back yard near the laundry area which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Administrator will provide pictures showing the items of furniture from the backyard were removed to CCL by POC Due Date.

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above Administrator Carrillo was unable to provide a document from the physician for bed rails approval for C2-C3 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2024
	Plan of Correction
1 2 3 4	Administator agrees to submit a physician's order for R2- R4 bed rails. The order will specify the length of the bed rail.

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024