565802468-10-28-2024-29-AS-MARO-DAGUN8-20241028154330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802468
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:44:43 PM

Document Has Been Signed on 10/28/2024 03:44 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMERICA'S CARE MANOR		FACILITY NUMBER:	565802468
ADMINISTRATOR/ DIRECTOR:	MARIA D. CALLES		FACILITY TYPE:	740
ADDRESS:	5794 KATHERINE STREET		TELEPHONE:	(818) 448-8641
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 6	DATE:	10/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Maria Calles		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:40 a.m. Upon arrival, there were two (2) staff and six (6) residents present. The LPA was greeted by the Administrator, Maria Calles and at this times, the reason for the visit was explained. Entrance interview conducted.

Starting at 10:45 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 11:05 a.m. Knives and sharps were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 105 degrees Fahrenheit at 11:07 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguisher was observed and fully charged on 05/17/2024. The LPA observed required postings throughout the common space. Activities were observed in the common areas. There is a working telephone on premises. Cameras observed in the common areas.

RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
	VISIT DATE: 10/28/2024

NARRATIVE

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Report Continued from LIC 809...

Hand washing signs were observed posted in the bathrooms. Starting at 10:50 a.m., the hot water temperature was measured in both bathroom and they were between the required range of 105 and 120 degrees Fahrenheit.

BEDDROOMS: There are four (4) total bedrooms in the facility; two (2) are designated as a shared rooms and two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. 24-hour wake staff. No staff bedroom on premises.

GARAGE: The garage was locked and inaccessible to residents at the time of the visit. There is an additional refrigerator with perishable food, in good condition. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. There is a washer and dryer inside the garage.

BACKYARD: The facility is fully gated/enclosed. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 11:15 a.m. and Personnel Records at 12:37 p.m.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

At 12:20 p.m., record review of Resident #1’s (R1’s) physician’s report, dated 10/04/2024 indicates R1 has no capacity for self-care; however, R1 is neither on hospice nor the facility have an exception request on file with the Department.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
	VISIT DATE: 10/28/2024

NARRATIVE

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Report Continued from LIC 809...

The Administrator stated they will be submitting an exception request to the Department.

Six (6) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one being a fire drill which was conducted on 09/18/2024.

MEDICATIONS: Medications review began at approximately 1:40 p.m. The medications are locked in a file cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are labeled and checked for expiration dates. Medications appeared to be given as prescribed at the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/28/2024 03:44 PM - It Cannot Be Edited

Created By: Martha Arroyo On 10/28/2024 at 02:58 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMERICA'S CARE MANOR	FACILITY NUMBER: 565802468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87615(a)(5)

Prohibited Health Conditions

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. 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 as R1 has no capacity for self-care and R1 is neither on hospice nor the facility have an exception request on file with the Department, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	The Administrator will submit an exception request for R1 to the Department or submit new medical assesment for R1 to CCL on or before 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:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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