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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601665
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:13:21 PM

Document Has Been Signed on 10/27/2022 12:13 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ELEGANT CARE INC.FACILITY NUMBER:
198601665
ADMINISTRATOR:JEWEL REESEFACILITY TYPE:
740
ADDRESS:834 E. 74TH ST.TELEPHONE:
(323) 821-1601
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 5DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Jewel Reese - Administrator TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control, medication and file review. LPA met with Jewel Reese Administrator and explained the reason for the visit.

The facility is licensed to serve six (6) non-ambulatory residents of which (1) may be bedridden, with an approved hospice waiver for (2). The home consists of 4 resident bedrooms, 1 bathroom, living room, dining area, and kitchen.

LPA Flores conducted a tour with Jewel Reese Administrator and observed the following:
Living/dining room sufficient sitting area, signs posted for prevention of COVID 19. Kitchen, food supplies were observed sufficient for 2 days worth of perishables and 7 days of non-perishables. Cleaning supplies were locked under the sink, and knives were locked in a cabinet. 4 resident bedrooms were observed and all have sufficient lighting, and the required furniture and bedding. Bathrooms were observed and are in working condition, hand washing signs posted and sanitary items provided. Bathroom #1(B1) water temperature was tested at 124.5 degrees F. and bathroom #2(B2) water was tested at 119.8 degrees F., which is not within the required 105 - 120 degrees F. Files were reviewed for 3 residents and medication was reviewed for resident resident #1(R1) and #2(R2), R1's last physician report was on 5/18/21 and R2's last physician report was on 5/4/20. Resident #3(R3) in room #3 were observed with half bed rails, no physician's order on file. Smoke/Carbon monoxide detectors were tested and in working condition. Fire extinguisher was observed outside the kitchen wall and last inspected on 2/18/22. No large bodies of water were observed. Outdoor shaded area provided. Administrator certificate was observed #

Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Administrator and a copy of this report, LIC 809D, and appeal rights was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
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 7
Document Has Been Signed on 10/27/2022 12:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/27/2022 at 11:40 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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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
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Based on observation, the licensee did not comply with the section cited above in bathroom #1 water temperature tested at 124.5 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee is to ensure water temperature is within the required 105-120 degrees F. at all times and will certify in LIC 9098 and submit to the department by 10/28/22.
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in R2 has half bed-rails in their beds which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Licensee will removed half bed rails and will request a physician's order for R2 by POC due date 10/28/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/27/2022 12:13 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/27/2022 at 11:40 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: ELEGANT CARE INC.
FACILITY NUMBER: 198601665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in R1's last physician's report was done on 5/18/21 and R2's last physician's report was done on on 5/4/20 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee will assist R1 and R2 with obtaining a current physician's report and submit a copy to the department by 11/10/22.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above exit doors do not have auditory device which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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Licensee will install auditory devices in each exit door and will submit pictures to the department by 11/10/22.
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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7