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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608975
Report Date: 04/21/2021
Date Signed: 04/21/2021 12:44:51 PM

Document Has Been Signed on 04/21/2021 12:44 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,
, CA
FACILITY NAME:MY SERENITY BOARD AND CAREFACILITY NUMBER:
197608975
ADMINISTRATOR:MASTOV, ELLAFACILITY TYPE:
740
ADDRESS:6658 CAPISTRANO AVETELEPHONE:
(747) 242-1916
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
04/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Ella Mastov and Ariel MastovTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #31-AS-20200522093556

During today’s investigation, the LPA audited medications. During the medication audit, the LPA was unable to complete an accurate count of medications administered to Resident #1 (R1), as the LPA nor the staff were able to communicate the start date as to when medications were administered. The LPA spoke to Administrator Ella Mastov via phone, whom communicated that they understood the medication count, but the LPA explained that staff needed to be familiar with the system to ensure accuracy. The LPA explained that the staff were unable to communicate the start dates or system for assisting residents with the self-administration of medication. The LPA also shared that there was no documentation to confirm the medication administration system.

In addition, the LPA audited training files for Staff #2 and Staff #3 (S2, S3). The LPA observed that the staff only received six hours of initial medication training; yet, S2 and S3 required ten hours of initial medication training per regulation.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, today's report and appeal rights were reviewed and issued via email. Signatures were obtained.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/21/2021 12:44 PM - It Cannot Be Edited


Created By: Ashley Smith On 04/21/2021 at 12:03 PM
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
,
, CA

FACILITY NAME: MY SERENITY BOARD AND CARE
FACILITY NUMBER: 197608975

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
HSC
1569.69(a)(2)

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1569.69(a)(2) Employees assisting residents with self-administration of medication. The employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training... and 4 hours of other training or instruction...
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Complete the remaining four hours of medication training for S2 and S3. Submit proof of completion to CCLD by 4/30/2021.
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Based on record review, the licensee did not comply with the section cited above, as 2 out of 2 staff (S2, S3) did not have all of the medication hours completed, which poses a potential health and safety risk to residents in care.
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Type B
04/30/2021
Section Cited
CCR87465(a)(5)

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87465(a)(5) Incidential Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced byL
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The Administrator has agreed to do the following:
1. Complete an in-service medication training for staff, including S2 and S3. Submit proof of completion to CCLD by 4/30/2021.
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Based on medications review and interview, the licensee did not comply with the section cited above, as the LPA could not complete an accurate medication count, which poses a potential health and safety risk to residents in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021


LIC809 (FAS) - (06/04)
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