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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608984
Report Date: 07/22/2023
Date Signed: 07/22/2023 02:24:16 PM

Document Has Been Signed on 07/22/2023 02:24 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
Lookup Error,
, CA
FACILITY NAME:INFINITY ELDER CARE INCFACILITY NUMBER:
197608984
ADMINISTRATOR:DIVINIA C. CRUZFACILITY TYPE:
740
ADDRESS:9253 BALCOM AVETELEPHONE:
(818) 813-1736
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 2DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Raul Cruz-CaregiverTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Raul Cruz, Caregiver and explained the purpose of today's visit. Administrator is currently out and will not be able to assist LPA. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control:
Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has not submitted an Infection Control Plan.
Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements.

Operational Requirements:
A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan.
A Hospice Waiver for 5 residents is approved. Liability Insurance in the amount of ($3,000,000) in total annual aggregate has expired on 3/20/2021. Facility does not handle cash resources for the residents.
The last fire Drill was conducted on 11/19/2020. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single storey home located in a residential neighborhood. It is licensed for 6 non ambulatory, 1 of which may be bedridden. It consists of 5 resident rooms, 1 Staff bedroom/office, 3 full bathrooms, living room, family room, kitchen, dining room, attached garage and backyard. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 108.5-118.6 degrees Fahrenheit. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cameras are operational and available outside the home and living room area only. Smoke and carbon monoxide detectors are operational. The facility has (2) fire extinguishers located in the kitchen which are both expired, and were purchased on 6/30/2022. Cleaning supplies and toxic substances are inaccessible to clients.
*****CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2023
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984
VISIT DATE: 07/22/2023
NARRATIVE
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Staffing: A total of two (2) staff members provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility.

Personnel Records-Training: Administrator certificate expires 1/10/2025. Staff have criminal background clearance and training. Two (2) staff files were reviewed. Personnel records have health/TB screenings and First Aid/CPR training. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation.

Resident Records-Incident Reports: A total of two (2) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records.

Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full bed rails for one (1) resident was missing in the resident's files and unavailable for review.



Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Facility does not have an activity calendar available nor posted in the home.

Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained).Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly.

Incident Medical and Dental: Two (2)centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices.
Records of resident Appraisal and Needs services plans are part of Emergency training.Fire Drill was last conducted on 11/19/2020.

Residents with Special Health Needs: One (1) resident is receiving home health services. No one receives hospice care. Full bed rails for one (1) resident was missing and unavailable for review. "No smoking In Use" sign was not posted on the resident (R1) door.


Pursuant to Title 22, deficiency was cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report was provided to Raul Cruz, Caregiver.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:31 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, theAdministrator did not comply with the section cited above in that LPA observed used needles in a red plastic disposal container on patio chair in the backyard not disposed of properly. Caregiver stated it will be thrown in the black trash bin which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 07/24/2023
Plan of Correction
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2
3
4
Administrator shall submit a plan on how to properly dispose of used needles and make it inaccessible to residents in care. Plan will be submitted to CCL/LPA by POC due date.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, theAdministrator did not comply with the section cited above in that one resident (R1) had a full length bed rail and caregiver cannot provide copy of the Physician's order and R1 is not under Hospice care which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 07/24/2023
Plan of Correction
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2
3
4
Administrator will obtain a physician order for full bed rail and submit pictures of resident bed and copy of the physician orders to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:31 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that 1 scissor was observed to be on top of the nightstand and 2 screw drivers were observed in an unlocked drawer in the vacant bedroom. which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 07/24/2023
Plan of Correction
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Administrator shall ensure all sharps are locked and inaccessible to residents in care at all times. Staff put away the scissor and screwdrivers immediately. ****Cleared during the visit.*****
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:31 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the Administrator did not comply with the section cited above in that caregiver cannot provide a copy of the Infection Control Plan and unsure if the plan has been submitted to Licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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3
4
Administrator will develop and submit a copy of the Infection Control Plan as required by Licensing. The plan will be submitted to CCL/LPA by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the Administrator did not comply with the section cited above in which the facility's liability insurance coverage with general aggregate limit of $3,000,000.00 has expired on 3/20/2021 which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator will renew the Liability Insurance and submit a copy of the valid insurance to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:31 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the Administrator did not comply with the section cited above in that the facility does not have written planned activities for the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator shall submit the planned activities for the residents in care to CCL/LPA by POC due date.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that LPA did not observe a 'No smoking-Oxygen in Use' sign in bedroom #4 where a resident uses oxygen on as needed basis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator will submit a proof that a non smoking/oxygen sign has been posted and submit photos to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:31 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the Administrator did not comply with the section cited above in that the exit door from the kitchen leading to the side yard did not have an auditory device which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
1
2
3
4
Administrator will install a door buzzer/auditory device on the exit door and submit photos and receipts to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 01:47 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
 LPA observed 2 fire extinguishers on the floor in the kitchen area that were purchased on 6/30/2022 and should be replaced every year which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 08/04/2023
Plan of Correction
1
2
3
4
The facility will have the current fire extinguishers serviced or replaced by the POC due date. Proof of purchase or service will be submitted to LPA for review.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/22/2023 02:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/22/2023 at 02:07 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: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
87465
Incidental Medical and Dental Care
(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:
(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the Administrator did not comply with the section cited above in that the caregiver cannot provide the Medication Administration Records for 2 residents in care which poses an immediate health, safety or personal rights risk toresidents in care.
POC Due Date: 07/24/2023
Plan of Correction
1
2
3
4
Administrator shall generate and update the Medication Administration records for 2 residents in care and submit proof to CCL/LPA by POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023


LIC809 (FAS) - (06/04)
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