ELLEE RESIDENTIAL CARE #2

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above as the facility was not maintained in current Fire Safety regulations which poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee will follow all instructions provided by LABDS and LAFD and will submit an LIC200 and updated facility sketch to CCLD by 08/19/2025 to request a new fire clearance.

Deadline recorded: Aug 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in that the facility does not have completed LIC308s- Designation of Facility Responsiblity on file designating the authority and responsible staff to manage the facility when the Administrator is not present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care. The Administrator is on call during the day but not present at the facility until the evening.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction The Licensee will complete LIC308 for every shift that the Administrator is not present at the facility and maintain in the respective staff's file for Department review when requested. Plan of correction to be completed and faxed to the Department by 10/14/24.

Official classification

Type B

Official code

1569.267(d)

Regulation authority

HSC

What the official deficiency says

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above per interview with the Administrator and request for inservice training logs, facility was not able to provide evidence of intial and ongoing personal rights training for all members of its staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will ensure that all required initial training and ongoing training is provided to its staff. Evidence of all inservice training will be documented and maintained in the employees' file for review by the Department. The training logs should have the following information - date of the training, the subject of the training, hours of training, name of the instructor, address, telephone number, training materials. Submit evidence to the Department by 10/14/24

Official classification

Type B

Official code

1569.157(f)(3)

Regulation authority

HSC

What the official deficiency says

(3) If a facility does not have a resident council, upon admission, the facility shall provide written information on the resident’s right to form a resident council to the resident and the resident representative, as indicated in the admissions agreement. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above, the facility Admission Agreement does not address the resident's right to Resident Council which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will review the Admission Agreement and make updates to the Admission Agreement to include information about the right to create a Resident Councill. Licensee will also provide every current resident and their family with informaiton about the Right to Resident Council by 10/14/24.

Official classification

Type B

Official code

1569.157(h)

Regulation authority

HSC

What the official deficiency says

(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the factiity, " Rights of Resident Council " was not observed posted anywhere in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will post " Rights of Resident Council " in a prominent location in the facility by 10/14/24.

Official classification

Type B

Official code

1569.158(d)

Regulation authority

HSC

What the official deficiency says

(d) A family council shall be provided with adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, per tour of the facility there was no bulletin board or other posting area for the display of meeting notices, information and news letters which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will ensure that if a family council is formed that adequate space is provided to hold meeting, posting of meeting notices, information and news letters by 10/14/24

Official classification

Type B

Official code

1569.158(g)(2)

Regulation authority

HSC

What the official deficiency says

(2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written information to the resident’s family members, friends, or resident representatives identified during the admission process of their right to form a family council. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above per review of the Admission Agreement or documents there is no information provided to the resident or family about the right to create a family council which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will update the Admission Agreement to include information on creating a family council by 10/14/24.

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above, the facility has internet access and does not have a internet access device with videoconferencing, camera, microphone dedicated for resident use] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will provide residents with an internet access that meets Title 22 requirements noted above by 10/14/24.

Official classification

Type B

Official code

1569.319(b)(1)

Regulation authority

HSC

What the official deficiency says

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (1) The device shall be available in a manner that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above, per interview conducted, the facility does not have a internet access plan in place to allow a resident to access it for personal or confidential information with a reasonable level of priivacy which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction Licensee will put a internet access plan in place that will allow all residents to access the device within a reasonable time and with the ability to have personal privacy if needed. Provide the facility plan by 10/14/24.

Official classification

Type B

Official code

1569.319(b)(2)

Regulation authority

HSC

What the official deficiency says

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above the facility does not have a facility plan in place to allow residents to have shared access among all residents in the facility during reasonable hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/15/2024 Plan of Correction LIcensee will put together a plan that will allow all residents to use the internet access device during reasonable hours.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, the cabinet under the kitchen sink that houses the knives and cleaning solutions and the garden shed that contained a bottle of Round Up Weed and Grass Killer was left unlock during the visit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/12/2023 Plan of Correction Licensee will ensure that all cabinets that contain sharp knives, toxins, poisons or any item that could pose a risk to the residents in care are locked and made inaccessible at all times. The garden shed and the cabinet under the sink was locked at the time of the visit.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (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: 2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above per review of facilty records, Sandra Yemima and Susanty Jakarta both hired on 8/29/23 were cleared on 8/15/223 but had not requested a transfer of their criminal record as of today's visit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/12/2023 Plan of Correction Licensee will ensure that all staff, volunteers or any individuals who are required to obtain a criminal record clearance, also request a transfer of their criminal record clearance. Submit an original LIC9182, LIC508 with a legible copy of their driver license to request the transfer or contact Guardian to obtain an account and associate Sandra Yemima and Susanty Jakarta to the facility by POC datte - 10/12/23te. CIVIL PENALTIES WERE ASSESSED

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the backyard and side of the facility contained many items such as a vanity, glass sliding doors, mattress, plastic buckets, mirrors, ladders, wooden boards, plastic bins, sinks, mops, brooms, gardening tools that need to be stored away or discarded, over grown grass and weed need to be cut which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee shall ensure that the facility inside and outside are clean, safe, sanitary and in good repairs at all times. Licensee will discard or store all items that need to be retained from the backyard and along the sides of the facility and cut the overgrown weed and grass by POC date of 10/18/23

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above per tour of the resident bedrooms. Dressers were not observed in Bedroom #1 and Bedroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee will provide dressers to residents in Bedroom #1 and Bedroom #2 that meet Title 22 requirements of 8 cubic feet per resident by 10/18/23

Official classification

Type A

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (e)Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the 12 feet deep facility pool had no water at the time of the visit and the netted fence did not meet state or local building codes. The netted fence did not secure the pool or make the pool inaccessible to the dementia resident in care or able to prevent a fall injury which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/12/2023 Plan of Correction Licensee will provide Licensing with a written plan of action as to how the swimming pool will be secured and made inaccessible for the dementia resident or any other resident from sustaining a fall injury until permanent measures can be made to secure the pool by 10/12/23. The licensee will notify the Department once the permanent measures have been completed.

Official classification

Type B

Official code

87216(a)(1)

Regulation authority

CCR

What the official deficiency says

Bonding(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. (1) The amount of the bond shall be in accordance with the following schedule: Total Safeguarded Per Month Bond Required $750 or less $1,000 $751 to $1,500. $2,000 $1,501 to $2,500 $3,000 Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above per information obtained that the Facility is payee for Resident# 3's social security benefits and PACE program and has not maintained the the required Surety Bond in the appropriate amount which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee will ensure that a current Surety Bond iwith the appropriate coverage is maintained by the facility if they plan to handle the residents' money or become payee for any resident.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

Admission Agreement: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above per review of Resident #2's file there was a blank Admission Agreemnt on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee will ensure that an Admission Agreements are completed for every resident who is admitted to the facility, The Original will be maintained in the resident's file and a copy provided to the resident, conservator or responsible party by 10/18/23

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Person with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the facility, it was observed that there is no auditory device installed on the front door, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee will ensure that alll facility exit doors are installed with auditory devices or other staff alert features to monitor exiit and to conduct monthly checks to ensure that the battery is still in working order. Provide evidence that the auditory device has been placed on the front door by POC date

Official classification

Type B

Official code

87307(a)(E)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the resident rooms bedroom #3 does not have a closet, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2023 Plan of Correction Licensee will provide the resident in Bedroom #3 with a portable closet by POC date