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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609731
Report Date:
03/19/2024
Date Signed:
04/04/2024 11:18:27 AM
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
ADMINISTRATOR:
KOSOYAN, GRIGOR
FACILITY TYPE:
740
ADDRESS:
16301 NORDHOFF STREET
TELEPHONE:
(323) 314-2996
CITY:
NORTH HILLS
STATE:
CA
ZIP CODE:
91343
CAPACITY:
6
CENSUS:
3
DATE:
03/19/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:32 AM
MET WITH:
Grigor Kosoyan- Licensee
TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Liezl De La Cerra conducted an annual required visit and inspection of the facility. LPAs was greeted by licensee, Grigor Kosoyan and was explained the reason for the visit.
At 11:00 AM, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the entrance. The charge date is 8/31/2023. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; 1 bedridden; hospice waiver for 5.
Kitchen:
The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. The menu was posted for review. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the laundry.
Bedrooms:
There were four (4) bedrooms designated for residents' use. Bedroom #1 and bedroom #3 is vacant, bedroom #2 and bedroom #4 is is shared. Although bedroom #3 is vacant, the room has been used for staff storage. Deficiency will be cited on LIC 809-D. Resident bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting.
Bathrooms:
There are two (2) bathroom at the facility, one for staff and the other one is designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 118.8 degrees Fahrenheit for bathroom #1 located in the hallway beside room #2. Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
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
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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
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
VISIT DATE:
03/19/2024
NARRATIVE
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There was enough clean linen available in the cabinets in the hallway.
Common Areas:
LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.
Infection control
: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.
Surrounding Grounds
: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool, this is properly fenced and locked. The garage detached and is used for storage.
Laundry service:
There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located in the kitchen.
Staff Files
: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is located beside the living room by the entrance. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.
Medications
are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has NOT been logged in the medications log with proper documentation from the clients’ doctor. Deficiency will be cited on LIC 809-D.
Continue to LIC 809-C
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
VISIT DATE:
03/19/2024
NARRATIVE
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Proper medication dispensing instruction are followed and checked for contamination. Medication was not given to resident for morning dosage. Deficiency will be cited on LIC 809-D. First-aid has all proper items and is current.
Resident records
were reviewed for requirements and legibility: LPA reviewed client’s files for physician's report, TB test, admissions agreement, personal rights, needs and service plan, and identification and emergency information needs to be done when getting a new resident. Deficiency will be cited on LIC 809-D. Planned activities are offered.
Facility is not within CA code of Regulations Title 22 or Health and Safety Code. Citation has been issued on LIC 809-D. Exit interview conducted, copy of report has been issued and discussed.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
11
of
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Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Medication needs to log in centrally stored medication record.
Type B
Section Cited
CCR
87506(b)(13)
Resident Records
(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents funcational capability records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Resident needs to be asses upon arriving at the facility.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents admissions records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Admission records needs to be signed when taking in new resident.
Type B
Section Cited
CCR
87456(a)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents records are empty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Resident needs to have all their proper paper work signed.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Appraisal records need to be done when taking in new client.
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Need physician report and TB test
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Appraisal needs to be done when taking in new clients.
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(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) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Appraisal needs to be done for every resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
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.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Physician report needs to be done before admitting a new resident.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Physician report needs to be done for every resident.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(5)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents physician report records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Physician report needs to be done.
Type B
Section Cited
HSC
1569.885(c)
Admission Agreements
(c) The admission agreement shall inform a resident of the right to contact the State Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents admission agreement records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Admissions agreement needs to be signed.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
8
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)(2)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (2) Information on the resident's attending physician as specified in Section 87506(b)(7).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents physician report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Identification and emergency information is needed to be filled.
Type B
Section Cited
CCR
87508(a)(3)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: (3) Information on the resident's responsible person as specified in Section 87506(b)(6).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Please fill in emergency and indentfication form.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
9
of
11
Document Has Been Signed on
04/04/2024 11:18 AM
- It Cannot Be Edited
Created By:
Leslie Ngo-Castaneda
On
03/19/2024
at
12:11 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
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
G & A CARE
FACILITY NUMBER:
197609731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
Appraisal needs to signed and done when admitting a new resident.
Type B
Section Cited
HSC
1569.695(e)(3)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 residents appraisal records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/02/2024
Plan of Correction
1
2
3
4
CSMDR needs to be filled in with all proper medications.
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:
Nichelle Gillyard
LICENSING EVALUATOR NAME:
Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE:
03/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/19/2024
LIC809
(FAS) - (06/04)
Page:
10
of
11