197609980-9-3-2021-29-AS-SURA-C6HVY4-20210903165029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 09/03/2021
Date Signed: 09/03/2021 04:52:57 PM

Document Has Been Signed on 09/03/2021 04:52 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMY'S PARADISE HOME OF ANGELS INC.		FACILITY NUMBER:	197609980
ADMINISTRATOR:	MADDEN, TAMME		FACILITY TYPE:	740
ADDRESS:	11950 ROSCOE BLVD		TELEPHONE:	(310) 913-6161
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 4	DATE:	09/03/2021
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Armine Grigoryan		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst, Sandra Urena conducted an announced Post Licensing Visit, and an Infection Control Inspection. LPA Urena arrived at the facility at 10:45am, met with Licensee Armine Grigoryan, and explained the reason for the visit.

At 12:00 pm, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

INFECTION CONTROL: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control signage was visible at entrance. LPA observed that the supply of Personal Protection Equipment (PPE) was limited and not fully available. The facility’s cleaning protocol is sufficient.

Bedrooms: At 12:15pm, the LPA observed the residents’ bedrooms have clean bed linens and were in clean condition There is at least one chair, nightstand and sufficient lighting for each resident.

Bathroom: At 12:30pm, the LPA observed the bathroom, it had a tub and enclosed shower doors. The tub had grab bars, and a nonskid mat. It was in a clean condition. Paper towels were not available for hand drying.

Kitchen: At 12:35 pm, LPA observed the kitchen/dining area. Knives are stored in a locked pantry. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Freezer had a limited supply meat, the supply appeared to be only for two days. Emergency food supply was not available. Emergency water supply consisted of one- 24 cas bottled water, and two gallons of water.

Outdoor Area: At 12:45 pm, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Side gate is unlocked.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.	FACILITY NUMBER: 197609980
	VISIT DATE: 09/03/2021

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Medications: At 1:00pm the LPA observed that medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Medications were available for three of the four residents residing in the facility. Medication dispensing logs were not available at facility. Licensee stated that Medication Logs were removed by administrator.

Record Review:

Resident records: At 1:30pm, LPA Urena reviewed residents’ files for current Needs and Service plans, admission agreements, Consent forms, Safeguard for Personal Property/Valuables, TB, Personal rights. Three out of four residents’ files were not available at the facility. The only file available for review had all required documents available, but had an Appraisal/ Needs and Services Plan (1-4 pages) signed by resident, however pages two and three of the appraisals were blank. Licensee stated files were stored with the administrator. Files were not stored locally at facility.

Staff records: At 1:45 pm, the LPA conducted a file review of staff for criminal record clearances/associations/and current First Aid. All files had the required documentation. A personnel LIS search revealed six individuals associated to the facility. Two of the associated individuals were present at the facility during today’s visit. Staff have not been fit tested for N-95 masks.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided.

Deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of the report was issued

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/03/2021 04:52 PM - It Cannot Be Edited

Created By: Sandra Urena On 09/03/2021 at 03:53 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMY'S PARADISE HOME OF ANGELS INC.	FACILITY NUMBER: 197609980
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87506(a)

This requirement is not met as evidenced by: Licensee did not comply with the above citation, as three out of four residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents.
	Deficient Practice Statement
1 2 3 4	All residents’ records shall be maintained at the facility and shall be available to the licensing agency for review
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee to submit proof by 09/07/2021 of residents' files available for review upon inspection.

Type A

Section Cited

CCR

87465(c)(3)

This requirement is not met as evidenced by: Upon review of records, licesee did not comply with the above citation, as four out of four residents' records were missing the medication logs and were not available at facility upon request for review , which poses a potential health and safety risk to residents.
	Deficient Practice Statement
1 2 3 4	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.
	POC Due Date: 09/07/2021
	Plan of Correction
1 2 3 4	Licensee to submit proof by 09/07/2021 of four residents' medication logs.

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:

Sandra Urena

LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC809 (FAS) - (06/04)

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