Community Care Licensing

Document Has Been Signed on 05/12/2023 12:17 PM - It Cannot Be Edited

FACILITY NAME:	ANZA HOME CARE		FACILITY NUMBER:	198204998
ADMINISTRATOR:	RODRIGO RAMOS		FACILITY TYPE:	740
ADDRESS:	19917 ANZA AVENUE		TELEPHONE:	(310) 370-9613
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 6		CENSUS: 4	DATE:	05/12/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:42 AM
MET WITH:	Patricia Changco - House Manager		TIME COMPLETED:	12:53 PM

SUPERVISORS NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Mario Leon LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023

Link to Parent Document Below:

FACILITY NAME: ANZA HOME CARE	FACILITY NUMBER: 198204998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's measurement, the licensee did not comply with the section cited above in showing water temperature at 128.3 F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2023
	Plan of Correction
1 2 3 4	Administrator Shalani Ramos (A1) will lower the water temperature, to be within Title 22 regulations as listed above. A1 will submit media evidence (video) of the water temperature within Title 22 regulations , via email at Mario.Leon@dss.ca.gov, on or prior to the POC due date as 5/15/23.

(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 LPA's observation, the licensee did not comply with the section cited above, on 5/01/23, in having two knives left in the drying rack area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/01/2023
	Plan of Correction
1 2 3 4	LPA observed staff relocating the knives from accessible area to the locked drawer, inaccessible to clients while LPA was on-site.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Mario Leon LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023

Link to Parent Document Below:

FACILITY NAME: ANZA HOME CARE	FACILITY NUMBER: 198204998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in missing the above mentioned poster available on 5/01/23 and on 5/12/23 was replaced with 8.5"x12" sheet which is not the requested size which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2023
	Plan of Correction
1 2 3 4	LPA and A1 have agreed that the proper size poster will be displayed in the main entryway of the facility (either above the ombudsman poster, or near the facility sketch posted near the front entance of the facility. A1 will submit media evidence (photo) of the properly sized poster via email at Mario.Leon@dss.ca.gov on, or prior to, the POC due date listed above.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Mario Leon LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023

Link to Parent Document Below:

FACILITY NAME: ANZA HOME CARE	FACILITY NUMBER: 198204998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in not having any previous drills having been logged which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	LPA has assesed this deficiency as a repeated violation. There will be an immediate $250 fine. A1 will submit media evidence (scanned documents), via email at Mario.Leon@dss.ca.gov, of the latest drill to make sure the facility will remain in compliance. Moving forward, future drills will be conducted each quarter and will be kept on file for future record review.

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review the licensee did not comply with the section cited above in the lack of physician's orders for resident(s) using postural supports (bed rails) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	LPA and A1 have agreed that A1 will seek physician's orders for clients who require postural supports (bed rails). If A1 is unable to acquire the proper physician's orders, A1 will remove the bed rails. A1 will submit media evidence (photos AND scanned documents), via email at Mario.Leon@dss.ca.gov, to follow state licensing regulation in order to remain in state compliance.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Mario Leon LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023

Link to Parent Document Below:

FACILITY NAME: ANZA HOME CARE	FACILITY NUMBER: 198204998
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2023

(1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in not having any documentations / histories related to hospice training sessions which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/26/2023
	Plan of Correction
1 2 3 4	LPA and A1 have agreed that to remain in state compliance, A1 will submit media evidence (scanned documents) via email at Mario.Leon@dss.ca.gov, in order to remain in compliance. A1 has agreed to move forward with having all training documentation on file for future review.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Mario Leon LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023

FACILITY NAME: ANZA HOME CARE	FACILITY NUMBER: 198204998
	VISIT DATE: 05/12/2023