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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607689
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:16:46 PM

Document Has Been Signed on 04/29/2024 12:16 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:AMERICARE ASSISTED LIVING OF ROLLING HILLSFACILITY NUMBER:
197607689
ADMINISTRATOR/
DIRECTOR:		EDNA DIMALANTAFACILITY TYPE:
740
ADDRESS:4826 ROCKBLUFF DR.TELEPHONE:
(310) 422-5364
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 6CENSUS: 5DATE:
04/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Minda Olila-StaffTIME VISIT/
INSPECTION COMPLETED:
12:16 PM
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On 4/29/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Minda Olila/Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Of which (4) may be non-ambulatory and (2) bedridden. Approved hospice waiver for (1). Currently the facility has (5) clients in care.

The facility is a single-story structure located in a residential neighborhood. It has a ramp on the back door. It consists of (7) bedrooms, (2) full bathrooms, shaded back yard, front yard, laundry in the attached 2 car garage.

LPA toured the physical plant with staff. There were no bodies of water or obstructions on the premises. A total of (5) rooms and (2) bathrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were observed and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between 105F°. and 120F°.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689
VISIT DATE: 04/29/2024
NARRATIVE
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LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable.

A review of (3) residents' service files, (3) staff personnel files were checked. (3) Medication Administration Records (MAR) were reviewed. Discrepancies on documentation were found. Last facility disaster drill performed on: 3/1/24.

LPA observed the facility's infection control practices. Copy of liability insurance was provided to LPA during this visit. Facility Annual Fess not current. LPA told facility staff that the license fees are not current since 4/25/24. LPA spoke with Tammy, and she said fees were paid on 4/17/24.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-Cleaning agents found unlocked inside cabinet of second bathroom.

-Facility staff did not documented medication given for R#1 and R#2 on the days: 4/24, 4/25, 4/26, 4/27, and 4/28.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Minda Olila/Staff.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
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Document Has Been Signed on 04/29/2024 12:16 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 04/29/2024 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on [(observation), the licensee did not comply with the section cited above in having cleaning agents found unlocked inside cabinet of second bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2024
Plan of Correction
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Facility staff locked cleaning agents while LPA was present. As part of Plan of Correction, licensee will ensure all cleaning agents are lock at all times. Licensee will conduct a re-traininig for all facility staff on how to keep cleaning agents lock. Proof of training will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


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Document Has Been Signed on 04/29/2024 12:16 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 04/29/2024 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: AMERICARE ASSISTED LIVING OF ROLLING HILLS
FACILITY NUMBER: 197607689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in facility staff did not documented medication given for R#1 and R#2 on the days: 4/24, 4/25, 4/26, 4/27, and 4/28,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Licensee will ensure all facility staff will document medication given to residents in care at all times. As part an Plan of Correction, licensee will re-train all facility staff on how to properly document medications given to residents in care. Proof of training will be sent to LPA via email before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2024


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