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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801049
Report Date: 06/04/2021
Date Signed: 06/04/2021 10:17:42 AM

Document Has Been Signed on 06/04/2021 10:17 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LOVING CARE HOMEFACILITY NUMBER:
197801049
ADMINISTRATOR:MANAHAN, TEODORAFACILITY TYPE:
740
ADDRESS:735 E. HANKS STTELEPHONE:
(626) 969-2411
CITY:AZUSASTATE: CAZIP CODE:
91702
CAPACITY: 6CENSUS: 4DATE:
06/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Teodora Manahan; Administrator TIME COMPLETED:
10:33 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Teodora Manahan and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following were observed/inspected:
  • LPA and Ms. Manahan toured the home and inspected (4) client bedrooms, (1) staff bedroom, (2) bathrooms, kitchen, dining room, living room, family room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 113.5F which is within the required 105 - 120 degrees. Clients bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Clients beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is a carbon monoxide detector in the living room area of the home. There is a fire extinguisher located in the kitchen and it is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to clients. Cleaning supplies and toxins are locked in a kitchen cabinet and are inaccessible to clients. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • (3) out of the (4) client medications were reviewed. LPA did not observe accurate, current, records of centrally stored medications for the residents. LPA also observed Resident #1 had medication that was not stored in its original container.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2021
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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Document Has Been Signed on 06/04/2021 10:17 AM - It Cannot Be Edited


Created By: David Sicairos On 06/04/2021 at 09:56 AM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LOVING CARE HOME

FACILITY NUMBER: 197801049

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Medication Review, LPA observed Resident #1 (R1's) medications were prepared and placed in a weekly pill case. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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Administrator will not remove residents pills from their original containers and transfer them to other containers. Administrator will self-certify by POC due date.
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Medication Review, LPA did not observe accurate,current records of centrailly stored prescription medications for the residents in care. This poses a potential health, safety, and/or personal rights risk to the residents in care,
POC Due Date: 06/18/2021
Plan of Correction
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Administrator will provide accurate centrally stored medication logs for all residents in care 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:Rebecca Orendain
LICENSING EVALUATOR NAME:David Sicairos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2021


LIC809 (FAS) - (06/04)
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