NARRATIVE |
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25 | Licensing Program Analyst (LPA) Danyle Wolter arrived at the facility unannounced to conduct a Required 2 Year inspection. Upon LPAs arrival, S2 and S3 were present and contacted administrator, Narine Hannesyan (certificate # 6034425740 exp 3/31/19), who arrived at 9:15am. Facility has a hospice waiver for three (3) and currently has one (1) resident on hospice.
LPA conducted a file review at 9:20 am of two (2) staff records. S2 has criminal background clearance but is not associated to the facility, S3 has no criminal background clearance and is not associated to the facility. S1 and S2 do not have current First Aid training (exp 3/31/2017), staff has not completed twenty (20) hours of training in 2018. LPA reviewed five (5) residents files and found the files to be incomplete. R1 and R5 do not have physician reports, R1, R2, and R5 do not have Pre-Admission Appraisals, and R3 and R4 do not have reappraisals which have been completed in the last 12 months.
LPA and administrator toured the facility together at 9:50am, including but not limited to: common living spaces, resident bedrooms; bathrooms, staff room/office, kitchen, and backyard. Facility has a garage in the backyard that was locked and administrator did not have a key to open it for inspection. Residents bedrooms and bathrooms were clean and in good repair, water temperature measured at 105.6 degrees F in resident bathroom. LPA observed adequate supply of extra towels and linens. Food supply for 2-day perishable and 7-day non-perishable was adequate. There is a pool in the backyard, pool is surrounded by a gate and is locked and inaccessible to residents. LPA observed fire extinguisher is fully charged and was purchased 10/28/18. LPA observed smoke detectors are present throughout the facility and are dual units with carbon monoxide detectors built in, they were tested and in working order.
Report continued on LIC 809C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/15/2018
Section Cited
CCR
87355(e)(1)
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7 | 87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the | 1
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7 | Administrator agrees to obtain criminal record clearance for S3 and ensure S3 is associated to the facility before S3 returns. Administrator understands that S3 is not allowed in the facility until this is completed. Furthermore, administrator understands that it is her responsibility to ensure that |
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14 | Department or
This requirement is not met as evidenced by: when LPA arrived S3 was present at the facility and interacting with residents, S3 does not have criminal record clearance. Administrator told LPA that S3 has been volunteering in the facility for about a month and that she wanted to see how she did before she hired her. This poses an immediate health and safety risk to residents in care. | 8
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14 | S3 has criminal record clearance and is associated before returning.
**Immediate civil penalties assessed**
Proof of correction due to CCL by plan of correction date of 12/15/18.
Danyle.Wolter@dss.ca.gov |
Type A
12/15/2018
Section Cited
CCR87355(e)(2)
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7 | 87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced | 1
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7 | Administrator agrees to complete LIC 9182 for S2 and turn it in to the Regional Office at Monterey Park. Administrator understands that S2 is not to be present in the facility until they are associated. Furthermore, administrator understands and agrees that it is their responsibility to ensure that the |
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14 | by: upon LPAs arrival, LPA observed S2 to be present at the facility. LPA reviewed S2's file and did not observe a LIC 9182 for criminal record clearance transfer request to the facility. Administrator was unable to provide proof of transfer request. This poses an immediate health and safety risk to residents in care. | 8
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14 | transfer request is complete before S2 returns to work. Proof of correction due to CCL by 12/15/18.
**Immediate civil penalties assessed.**
Danyle.Wolter@dss.ca.gov |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/15/2018
Section Cited
CCR
87755(a)
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7 | 87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or | 1
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7 | Administrator agrees to review regulation 87755 and write a letter of understanding. Additionally, administrator agrees to ensure that a key is always at the facility to ensure garage is accessible. Proof of correction due to CCL by 12/15/18. |
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14 | without advance notice.
This requirement is not met as evidenced by: during LPAs tour of facility with administrator, LPA could not inspect garage outside because it was locked and administrator did not have a key. This poses an immediate health and safety risk to residents in care. | 8
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14 | Danyle.Wolter@dss.ca.gov
**Immediate civil penalties assessed** |
Type A
12/15/2018
Section Cited
CCR87465(e)
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7 | 87465 Incidental Medical and Dental Care (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. Both the physician's order and the label shall contain at least all of the following information. | 1
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7 | Administrator agrees to obtain physician orders for PRN medications or cease use. Additionally, administrator agrees to review regulation 87465 and write a letter of understanding. Proof of correction due to CCL by 12/15/18. |
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14 | This requirement is not met as evidenced by: during LPAs medication review, LPA observed R4 to have PRNs and Vitamins which did not have physician orders. LPA reviewed R4s 602 and R4 is unable to administer own PRN medications. This poses an immediate health and safety risk to residents in care. | 8
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14 | Danyle.Wolter@dss.ca.gov |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/15/2018
Section Cited
CCR
87465(h)(5)
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7 | 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. | 1
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7 | Administrator agrees to ensure that medication stays in its originally received container, administrator understands that medication cannot be prepoured. Administrator agrees to review regulation 87465 and send a letter of understanding to CCL by 12/15/18. |
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14 | This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 and R4 to have medications which were prepoured for 7 days in a morning/afternoon/evening in a 7-day pill container. Administrator was unable to show LPA original containers as they were stored in the garage and the garage was locked and unable to be accessed. This poses an immediate health and safety risk to residents in care. | 8
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14 | Danyle.Wolter@dss.ca.gov
**LPA provided administrator with link for medication guide.
http://ccld.ca.gov/res/pdf/MedicationsGuide.pdf |
Type A
12/15/2018
Section Cited
CCR87465(c)(2)
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7 | 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: | 1
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7 | Administrator agrees to obtain discontinue orders for R3s medication from physician. If physician states R3 still needs medications then administrator is to refill prescriptions. Proof of correction due to CCL by 12/15/18. |
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14 | (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 to have medications prepoured in a 7-day pill container but no other medications on hand. Administrator told LPA that R3 does not take medications but could not provide discontinue orders for the prescribed medications on R3's LIC 602. R3's medications are not being given per physician orders. This poses an immediate health and safety risk to residents in care. | 8
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14 | Danyle.Wolter@dss.ca.gov |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/15/2018
Section Cited
CCR
87411(c)(1)
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7 | 87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. (1) Staff providing care shall receive appropriate training in | 1
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7 | Administrator agrees to obtain First Aid Training for themself and ensure that staff have First Aid Training as well. Proof of scheduled first aid training due to CCL by 12/15/18.
Danyle.Wolter@dss.ca.gov |
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14 | first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by: during LPAs file review, LPA observed no staff to have current 1st Aid Training. This poses an immediate health and safety risk to residents in care | 8
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Type A
12/15/2018
Section Cited
CCR87411(a)
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7 | 87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...] | 1
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7 | Administrator agrees to ensure that facility staff is adequate in numbers to ensure that residents needs are met 24-hours a day. Proof of correction due to CCL by 12/15/18.
Danyle.Wolter@dss.ca.gov |
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14 | This requirement is not met as evidenced by: during LPAs inspection, LPA observed only administrator was able to assist all residents and prepare food for lunch. During file review, LPA observed the administrator is the only person associated to the facility and able to work. This poses an immediate health and safety risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/11/2019
Section Cited
CCR
87457(c)
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7 | 87457 Pre-Admission Appraisal - General
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. | 1
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7 | Administrator agrees to ensure that Pre-Admission appraisals are completed before residents move in. Furthermore, administrator agrees to complete appraisals on R1, R2, and R5. Proof of correction due to CCL by 1/11/19. |
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14 | This requirement is not met as evidenced by: during LPAs file review, LPA observed R1, R2, and R5 did not have Pre-Admission Appraisals completed before moving in. This poses a potential health and safety risk to residents in care. | 8
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14 | Danyle.Wolter@dss.ca.gov |
Type B
01/11/2019
Section Cited
CCR87458(a)
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7 | 87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. | 1
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7 | Administrator agrees to schedule appointments for R1 and R5 to have medical assessments completed. Proof of correction due to CCL by 1/11/19.
Danyle.Wolter@dss.ca.gov |
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14 | This requirement is not met as evidenced by: during LPAs file review, LPA observed R1 and R5 do not have medical assessments in their files. This poses a potential health and safety risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/11/2019
Section Cited
CCR
87463(c)
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7 | 87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
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7 | Administrator agrees to complete reappraisals for R3 and R4 by plan of corrections date of 1/11/19. Additionally, administrator agrees to create a calendar of when all residents reappraisals need to be completed. |
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14 | This requirement is not met as evidenced by: during LPAs review of residents files, LPA observed R3 and R4 to have appraisals which have not been updated in the last 12 months as required. This poses a potential health and safety risk to residents in care. | 8
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Type B
01/11/2019
Section Cited
HSC1569.625(b)(1)
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7 | §1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision | 1
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7 | Administrator agrees to create a calendar for what training needs to be completed in 2019. Calendar will include what training will be done each month to ensure all training and topics are covered. Proof of correction due to CCL by 1/11/19.
Danyle.Wolter@dss.ca.gov |
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14 | This requirement is not met as evidenced by: during LPAs file review LPA observed the only staff training completed in 2018 was dementia training, the other topics had not been covered. This poses a potential health and safety risk to residents in care. | 8
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14 | LPA printed out H&S Code 1569.625 in its entirety for administrator. |