Community Care Licensing

Document Has Been Signed on 11/22/2024 04:14 PM - It Cannot Be Edited

FACILITY NAME:	EXCELLENCE BOARD AND CARE LLC		FACILITY NUMBER:	198603661
ADMINISTRATOR/ DIRECTOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	12551 DOWNEY AVE.		TELEPHONE:	(818) 799-7218
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY: 6		CENSUS: 2	DATE:	11/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:46 AM
MET WITH:	Rey John Bertulfo, Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

SUPERVISORS NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
	VISIT DATE: 11/22/2024

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
	VISIT DATE: 11/22/2024

Link to Parent Document Below:

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA observed cleaning products stored inside a kitchen cabinet underneath the sink accessible to residents. The cabinet did not have a lock or other safety mechanism in place to prevent access. Cleaning products included (2) powder cleanser (Bar Keepers Friend). Located in the kitchen island cabinet were (2) cleaning sprays Weiman Stainless Steel and an unidentified cleaning solution. The cabinet did not have a lock or safety mechanism. Stored in the pantry cabinet unlocked and accessible to residents was a can of butane fuel (First Street brand). In the unlock laundry area was (2) Clorox and (1) detergent bottle which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2024
	Plan of Correction
1 2 3 4	Licensee will remove the disinfectants, and cleaning solutions and placed them in a secure location. Licensee to provide In-Service training for all staff on cleaning solutions being inaccessible to clients. The In-Service Training will include list of attendees’ names and attendees’ signatures. Licensee will provide proof of In-Service Training to licensee by POC Due Date

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) . R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) . R2's AM Medication - Eliquis 2.5 MG (Take 1 tablet by mouth every morning and evening) . R2's AM Medication- Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening).. R2's AM Medication - Risperidone 0.5 MG ( Take 1 tablet by mouth every morning and evening) November 4th - November 11th 2024 medication was not administered no supporting documents was provided for the reason. R2's Evening Medication - Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) was not administered no supporting documents was provided for the reason which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2024
	Plan of Correction
1 2 3 4	Licensee will provide LPA with thefollowing documents in-service training for all staff on medication, and that R1's and R2's physician was notified by POC Due Date. The In-Service Training will include list of attendees’ names and attendees’ signatures.

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024

Link to Parent Document Below:

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA observed in the office area a filing cabinet ajar and unlocked contents were residents and staff medication. In staff room #1 the door was unlocked and medication was present and accessible to residents. Located in the dresser in the dining room was a (1) bubble pack of pills Hydroxyzine HCL 25 MG in the drawer which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/23/2024
	Plan of Correction
1 2 3 4	Licensee will ensure that all medication is kept safe and in a locked place that is not accessible to person other than employees responsible. Licensee will provide in-service training for all staff on the ensuring medication is secured. The in-service training will include list of attendees names and attendees signatures. Licensee will provide proof of in-service training to CCL by POC Due Date.

Section Cited

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

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024

Link to Parent Document Below:

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above LPA observed a closet door in resident #1 (R1) room was inoperable. The issue appeared to be caused by significant rust damage to the door track, preventing proper opening and closing. LPA observed in the backyard outside the shed a mattress, shopping cart, television, two (2) dressers, and an unhinged door. On the side of the shed was broken pieces of tile which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee will ensure the facility and backyard is clean and in good repair for residents. Licnesee will provide pictures and/or recipts of closet door being fixed and cleaned of rust. Documents will be submitted to CCL by POC Due Date

Type B

Section Cited

CCR

87303(e)(2)

(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 observation, the licensee did not comply with the section cited above he one (1) half bath in the kitchen water temperature measured at 71.4 degrees f, restroom #4 water temperature measured at 86.7 degrees f., and restroom #9 outside water temperature measured below the 105 degrees f. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee will maintain water temperature between 105 - 120 degrees F, Licensee will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Documents will be submitted to CCL by POC Due Date

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024

Link to Parent Document Below:

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

Type B

Section Cited

CCR

87465(c)(3)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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: (3) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above PRN medication Trazodone Hyrochlor 50mg Tab for R2 is being given daily with no record of dosage and resident's response and both R1 and R2 was missing their medication sheet for the month of November 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee will provide LPA with thefollowing documents an up dated medication sheet for R1 and R2 and notified R2's physican that PRN medication has been given daily November 1st - November 22nd 2024.

Type B

Section Cited

HSC

1569.695(c)

(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 record review, the licensee did not comply with the section cited above Licensee Rey did not have any documents supporting an Emergency Disaster Drill was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee will conduct an emergency disaster drill and provide documentation to CCL by POC Due Date.

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024

Link to Parent Document Below:

FACILITY NAME: EXCELLENCE BOARD AND CARE LLC	FACILITY NUMBER: 198603661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/22/2024

Type B

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above LPA observed resident #1 (R1) with full bed rails and R2 with half bed rails. R1 is not receiving hospice care. Licensee does not a have a note from physician for half bed rails for R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a physician's order for R1 & R2's bed rails. The order will specify the length of the bed rail.

Section Cited

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

SUPERVISOR'S NAME: Fernando Fierros LICENSING EVALUATOR NAME: Tyler Reyes LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024