Community Care Licensing

Document Has Been Signed on 08/06/2024 02:19 PM - It Cannot Be Edited

FACILITY NAME:	ARCENE GUEST HOME II		FACILITY NUMBER:	306000622
ADMINISTRATOR/ DIRECTOR:	MAILA ENRIQUEZ		FACILITY TYPE:	740
ADDRESS:	508 MICHEL PLACE		TELEPHONE:	(714) 996-4717
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY: 6		CENSUS: 2	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Malia Enriquez Soliven		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

SUPERVISORS NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Section Cited

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

Type A

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above in three of three staff files, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	AD stated they would create a personnel record for themselves and each staff. AD stated they will provide LPA with proof via email by POC dae.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87355(e)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above in one of three staff presently working at the facility, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	AD stated individual will be immediately fingerprinted and proof provided to LPA via email by POC date.

Type A

Section Cited

CCR

87412(e)

(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on AD interview, the licensee did not comply with the section cited above as staff coverage is not currently being documented, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	AD stated they will have documented personnel records to demonstrate staff coverage necessary for facility operation and provide LPA with proof via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

HSC

1569.69(a)(2)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and individual interview, the licensee did not comply with the section cited above one of one individuals presently working at the facility assisting with the self-administration of medications, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	AD stated individual will no longer be assisting with self-administration of medication. Staff training will be conducted with appropriate staff and proof provided to LPA via email by POC date.

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and AD interview, the licensee did not comply with the section cited above, as multiple food items were found to be expired in the facility pantry and refrigerator, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	AD stated they will complete a thorough cleaning of the pantry and refrigerator and discard of any spoiled or expired food and provide proof to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation nd record review, the licensee did not comply with the section cited above, as they were unable to provide a copy of current, unexpired liability insurance, which poses/posed a potential safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated a copy of current, unexpired liability insurance will be obtained and a copy provided to LPA via email by POC date.

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, and AD interview, the licensee did not comply with the section cited above, as boxes, binders, papers, and miscellanous items were observed piled on top of each other on the counter tops and floor of dining room, and patio, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated items would be discarded or stored elsewhere to ensure clear pathways, and use of counterspace. AD stated they will provide LPA with picture proof via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87303(f)(1)

(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. 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, as solid waste is not being stored or disposed of in a manner that will not transmit communicable disease or odor, which poses a potential health and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated solid waste will be stored in a moveable bin with a tight fitting lid and disposed of in a manner that will not transmit communicable disease or odor and proof provided to LPA via email

Type B

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 and AD interview, the licensee did not comply with the section cited above, as disinfectants and cleaning solutions were observed to be accessible to residents, which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	AD immediately stored disinfectants and cleaning solutions where inaccessible to clients. AD stated staff training will be conducted regarding proper storage of items and proof provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and AD interview, the licensee did not comply with the section cited above in three of three staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be completed and proof provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

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 observation and AD interview, the licensee did not comply with the section cited above, as a PUB475 was not posted anywhere in the facility, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated PUB 475 poster will be posted, will be 20” x 26” in size, and be posted in the main entryway of the facility and proof provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

HSC

1569.313

Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient’s rights form, the facility’s policy concerning family visits and other communication with resident clients and shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and AD interview, the licensee did not comply with the section cited above, as a notice of visiting policy at a location in the facility that is accessible to residents and famililies was not available, which poses a potential personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated a notice will be posted of visiting policy at a location in the facility that is accessible to residents and families and proof provided to LPA via email by POC date.

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
1 2 3 4	Based on observation, and staff interview, the licensee did not comply with the section cited above in three of three resident medications which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated medication will be returned to its original received container and will no longer be transferred between container. AD stated staff training will be conducted and proof provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 in three of three resident files, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated appraisals will be conducted, signed, and dated for all residents and proof provided to LPA via email by POC date.

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 observation, AD interview, the licensee did not comply with the section cited above, as emergency drills are not being conducted or documented, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	AD stated emergency disaster drills will be conducted and documented to include the date, the type of emergency covered by the drill, and the names of staff participating in the drill and proof provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

FACILITY NAME: ARCENE GUEST HOME II	FACILITY NUMBER: 306000622
	VISIT DATE: 08/06/2024