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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880763
Report Date: 07/22/2024
Date Signed: 07/22/2024 04:33:33 PM

Document Has Been Signed on 07/22/2024 04:33 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NEW HOPE RESIDENTIAL ELDER CARE IIIFACILITY NUMBER:
331880763
ADMINISTRATOR/
DIRECTOR:		MIKENAS, ANNIE JANE ZFACILITY TYPE:
740
ADDRESS:36040 PEPPERDINE COURTTELEPHONE:
(951) 599-4585
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 6CENSUS: 5DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Licensee/Administrator Annie Jane MikenasTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 07/22/2024 at 12:05 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA Brown met with a staff and was granted entry to the facility. Licensee/Administrator Annie Jane Mikenas arrived at the facility during the visit. At the time of the visit there were three (three) staff present, and five (5) residents present.

The facility is a five (5) bedroom, two & half (2 & 1/2) bathroom home with a kitchen/dining area, living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) bedridden residents, serving mentally disabled seniors. The facility’s approved for six (6) hospice waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, labor laws, and the disaster plan were posted in a common area. Furthermore, LPA Brown observed the den converted to staff room. Deficiency will be issued. ***Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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 24
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763
VISIT DATE: 07/22/2024
NARRATIVE
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Sharps, and other dangerous items were kept inaccessible to residents in care. However, LPA Brown observed two (2) gallons of chemicals inside the shed at the backyard, not locked, and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a Medicine Cabinet with the resident’s medications locked. LPA Brown observed incomplete first aid kit. No bandages or roller of bandages in the facilty's first aid kit. Deficiency will be issued. Also, no First Aid Manual approved by the American Red Cross, the American Medical Association or a state federal health agency at the facility. Deficiency will be issued.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present at the facility during the visit. However, LPA Brown observed insufficient staff to cover night shift as required for facilities with dementia residents. Deficiency will be issued.

Record Review: LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Brown observed resident files reviewed were complete. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. LPA Brown found that one (1) of the four (4) staff do not have Health Screening Report on file. Deficiency will be issued. Also, three (3) of four (4) staff do not have TB completed and no TB Test Result on File. Deficiency will be issued. Furthermore, LPA Brown observed no required trainings provided to Staff #4. Deficiency will be issued. Medications/Medication Administration Record (MAR) were audited for three (3) residents, and LPA Brown observed no issue.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Licensee/Administrator Annie Jane Mikenas.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the two (2) gallons of chemicals in the shed at the backyard were locked and making it not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of all staff training log to LPA Brown on Plan of Correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) completed the required Health Screening Report
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to submit proof of S2 Medical Appointment to complete the required Health Screening to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) completed the required Tuberculosis (TB) Test and TB Test Result maintained in their file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to submit proof of Medical Appointment of S2, S3 and S4 to complete the required TB Test to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing the required job training to Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to provide S4 the required job training and submit proof to LPA Brown on PLan of Correction (POC) due date,
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the 20 hours training requirements were provided to Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to provide the proof of enrollment on the required 20 hours training to S4 and submit proof to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuroing that the required 12 hours of dementia training was provided to Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to provide proof of enrollment of S4 on the required 12 hours of dementia training to LPA Brown on POC due date.
Other Provisions

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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 6 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that a first aid manual approved by the American Red Cross or the Amercian Medical Association is available at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to obtain a first aid manual approved my red cross or american medical association and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by having full bed rail for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee stated to remove all full bed rail for R1, R2, R3 and R4 and submit proof to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 7 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by altering the den at the facility to a staff room without obtaining a building permit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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2
3
4
Licensee stated to obtain building permit and write a letter to CCLD to notify alteration completed at the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not providing the required postural support training to Staff #4 (S4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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2
3
4
Licensee stated to provide the required postural support training to S4 and submit proof to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 8 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:12 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

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 by not providing the required four (4) hours training to Staff #4 on the care, supervision and special needs of residentsin which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
1
2
3
4
Licensee stated to provide the required 4 hours of training to S4 and submit proof to LPA Brown on POC due date.
Type B
Section Cited
CCR
87465(a)(8)(C)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (C) Bandages or roller bandages.

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 by not ensuring that the facility have a complete first aid kit as evidenced of missing bandages or roller bandages
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
1
2
3
4
Licensee stated to purchase or obtain bandages or roller bandages and submit proof to LPA Brown on POC due date.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 9 of 24
Document Has Been Signed on 07/22/2024 04:33 PM - It Cannot Be Edited


Created By: Melody Brown On 07/22/2024 at 03:31 PM
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
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HOPE RESIDENTIAL ELDER CARE III
FACILITY NUMBER: 331880763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)(A)
87705 Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

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 by not having a staff scheduled to work the night shift as required for a facility with dementia residents
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee stated to submit an updated Personnel Report (LIC500) and Staff Schedule indicating Night Shift coverage to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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