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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601898
Report Date: 07/01/2021
Date Signed: 07/01/2021 12:27:07 PM

Document Has Been Signed on 07/01/2021 12:27 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LADERA VISTAFACILITY NUMBER:
198601898
ADMINISTRATOR:MARK STEVEN CUMMINGSFACILITY TYPE:
740
ADDRESS:6502 SOUTH SHERBOURNE DRIVETELEPHONE:
(310) 216-9577
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 6CENSUS: 4DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Anna Miranda, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennifer Jones and Jade Jordan conducted an unannounced visit to Ladera Vista. The purpose of today’s visit was to conduct the annual inspection and to observe the infection control practices. LPAs met Anna Miranda. Facility is licensed for 4 non-ambulatory residents and 2 bedridden residents. The facility also has an approved hospice waiver for 6 residents. The facility currently has 2 non-ambulatory residents and 2 bedridden. Some of the residents are diagnosed with Dementia or are receiving home health or hospice services. The facility does not handle any of the residents’ money..

LPAs and the administrator toured the physical plant, checked food service, medications, reviewed staff records and reviewed resident files for medical status and first aid kit.. The facility conducted last fire drill 05/11/2021. The home consists of 6 resident bedrooms, 3 resident bathrooms, 1 staff bathroom, living room, dining room, admin office and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid tile was in place. LPA measured water at 111 degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All doors have auditory alarms.

Kitchen was checked and observed. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. Outside grounds were toured. In ground pool observed with gate around it. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Cont-9099C

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/01/2021 12:27 PM - It Cannot Be Edited


Created By: Jennifer Jones On 07/01/2021 at 11:23 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LADERA VISTA
FACILITY NUMBER: 198601898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)(1)
For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
The specific symptoms which indicate the need for the use of the medication


This requirement is not met as evidenced by: During medication review, LPAs observed residents medications stored without prescription labels.
Deficient Practice Statement
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During medication review, LPAs observed residents medications stored without prescription labels which poses/posed a potential health, safety risk for residents in care.
POC Due Date: 07/12/2021
Plan of Correction
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The administrator will provide LPA with pictures of prescription labels for resident's medications by POC due date.
Type B
Section Cited
CCR
87465(d)(3)
If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: The date and time the… …medication was taken

This requirement is not met as evidenced by:
Deficient Practice Statement
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During medication review, LPAs did not observed morning signatures by staff for medication that was administered at 9:00. LPAs reviewed the medications at 11:00am. Admin stated that the 3pm med tech signs off on morning medications. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2021
Plan of Correction
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The administrator will provide LPA with a new plan to indicate that all signatures are documented and all individual staff who administer medication is held accountable.
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:Michael Cava
LICENSING EVALUATOR NAME:Jennifer Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


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Document Has Been Signed on 07/01/2021 12:27 PM - It Cannot Be Edited


Created By: Jennifer Jones On 07/01/2021 at 11:51 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LADERA VISTA
FACILITY NUMBER: 198601898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(5)(A)
Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
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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During the tour, LPAs observed half bed rails for non-ambulatory residents in rm #1 and rm #4. LPAs did not observe prescriptions from the doctor for half bed rails in resident's files
This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2021
Plan of Correction
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The administrator will provide prescriptions for half bedrails for residents or remove half bed rails by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Michael Cava
LICENSING EVALUATOR NAME:Jennifer Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2021


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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LADERA VISTA
FACILITY NUMBER: 198601898
VISIT DATE: 07/01/2021
NARRATIVE
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During the visit, LPAs observed the facility infection control practices. Upon entry, LPAs temperature was taken, LPAs signed in and answered covid -19 questionnaire. LPAs observed a screening station with sanitizer at the facility entry and additional sanitation supplies in a closet located in room 5 (vacant room). LPAs observed a sign in sheet and temperature log for visitors. LPA observed staff wearing mask. Each client has their own individual room for isolation and required postings are throughout the facility. The administrator advised LPAs that visitors are allowed during visitor hours between 11am-8pm have the option to meet with the residents inside or outside by appointment only.

Advisory Notes:

  • The administrator will provide documentation from R1's conservator indicating that it is ok for resident to be relocated temporarily in staff room until the renovation is completed in resident's room. The administrator stated that Rm #5 will be completed in two-three weeks and will notify CCL when resident is moved.
  • The administrator will removed PPEs in the closet located in room 5 before resident is relocated to the room.
  • The administrator will replace missing upper cabinet door in the kitchen where dishes are stored.

The following deficiencies was observed:
  • During medication review, LPAs observed medications with out labels and a morning signature missing for today's 07/01/21 morning medication given at 9:00am.
  • During the tour, LPAs observed half bed rails for non-ambulatory residents in rm #1 and rm #4. LPAs did not observe prescriptions from the doctor for half bed rails in resident's files.

Deficiencies cited on 9099 D

Exit interview conducted and a copy of the report was furnished.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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