Health conditions and treatments
Cited in 2 reports, with 5 deficiencies in total.
EMVY BOARD AND CARE FACILITY
14164 COHASSET STREET, Van Nuys CA 91405
6 bedsLatest official report Aug 19, 2026Licensed
Additional info
- Telephone
- (818) 947-1711
- Licensee
- EMVY BOARD AND CARE FACILITY, INC.
- Administrator
- EMMA KOCHINYAN
- Contact
- EMMA KOCHINYAN
- License first date
- Aug 7, 2013
- License effective date
- Aug 7, 2013
- District office
- WOODLAND HILLS N.ASC · (818) 596-4334
- Regional office
- 29
- Clients served
- 935 - ELDERLY
Summary
The available records show 6 Type A and 27 Type B deficiencies for this facility.
- Most recent inspection
- Aug 19, 2026
- Most recent deficiency
- Aug 19, 2026
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 1,564 Los Angeles County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 5 reports for this facility: 5 inspections, 0 complaint investigations, and 0 licensing or administrative records.
Those records contain 6 Type A and 27 Type B deficiencies.
1 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 5
- Recorded deficiencies
- 33
- Type A deficiencies
- 6
- Type B deficiencies
- 27
- Substantiated complaints
- 0
- Repeated topics
- 4
More than the typical 4
1 in the last 12 months
Well above the typical 1
1 in the last 12 months
Most this size have none
1 in the last 12 months
Most this size have none
0 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Medical and dental care
Cited in 2 reports, with 4 deficiencies in total.
Fire safety and emergency preparedness
Cited in 2 reports, with 2 deficiencies in total.
Staffing, personnel, and training
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
Fire safety and emergency preparednessType A
- 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as it was observed during the testing of the hardwired smoke detectors, that the magnates that hold the 2 fire rated doors mounted on the entrance to the resident hallway and on bedroom #3, did not activate to release the doors to secure the resident rooms when the smoke detectors were tested which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/20/2026 Plan of Correction The Licensee will have the magnates used to hold the 2 fire rate doors open iand the hardwired smoke detector system nspected to determine what is causing the magnates to fail to activate and fix the problem. The Licensee will provide evidence of the correction or self certify that the problem with the magnates have been corrected by 8/20/26
Plan of correction recorded
Correction not verified in available records
Inspection
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(b)
- Regulation authority
- HSC
What the official deficiency says
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: 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 in all 2 counts as no LIC308s were completed were not observed in staffs' files for the morning and night shift which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will ensure that an LIC308 designating a responsible staff for each shift is completed and maintained in the staff file for when the Administrator is not present at the facility by 9/4/25
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(b)(2)(C)
- Regulation authority
- CCR
What the official deficiency says
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview with the Administrator, the licensee did not comply with the section cited above in all 4 counts. Staff have not been provided with PPE training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will ensure that all staff are provided with PPE training when hired and annually thereafter. Licensee will provide evidence that the staff have been provided with PPE training by 9/4/25
Plan of correction recorded
Correction not verified in available records
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87208(c)
- Regulation authority
- CCR
What the official deficiency says
(c) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606, Care of Bedridden Residents. 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 as per review of the Plan of Operations, there was no bedridden plan observed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will review their Plan of Operations and update the Plan of Operations to address how the care of Bedridden residents wiill be addressed by 9/4/25
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(d)
- Regulation authority
- CCR
What the official deficiency says
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 in all counts as copies of CEUs and a current Administrator Certificate was requested and the Administrator could not provide evidence that they were recertified as an Administrator] which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will contact the Administrator Certification Unit and obtain evidence that she is still a certified Administrator. The Licensee will provide a copy of the Administrator to LPA for review by 9/4/25
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: 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 as it was observed that Resident #4 has PRN Ambien and Acetaminophen and does not have a completed PRN Authorization by the physician on file. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will contact the prescribing physician to obtain a complete PRN Authorization Letter for the PRN medications and maintain in Resident #4 file by 9/4/25
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)(3)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 as it was observed that Resident #4 who has PRN Ambien was given a daily dose from 7/16/25 and there is no documentation of the date it was dispensed, no doctor instructions, time it was dispensed and no results of the dose cocumented by the staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will provide a written plan of action as to how she will ensure that all PRN medications are documented when it is dispensed and submit to the Department by 9/4/25
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)(1)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as the facility sketch does not identify the meeting point which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will update the facility sketch and note the assembly point on all facility sketches. A copy of the updated facility sketch will be provided to Licensing by 9/4/25
Plan of correction recorded
Correction not verified in available records
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 87632(d)(2)
- Regulation authority
- CCR
What the official deficiency says
Hospice Waiver (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. 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 as it was observed that Resident #4 has been receiving hospice services since 4/22/25 and it has not been reported to the Department which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will submit a notice of Hospice Initiation for Resident #4 to the Department by 9/4/25
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(3)(A)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and observation, the licensee did not comply with the section cited above as Resident #2 was observed with a oxygen concentrator for as needed use and 2 full tanks of oxygen was observed stored in the garage for a former resident which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction The Licensee will immediately notify the local fire department in writing of the use of the oxygen concentrator and the presence of oxygen tanks locate in the garage by 8/29/25.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(3)(B)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation , the licensee did not comply with the section cited above as there were not signs observed posted on the doors that there is oxygen in use at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction The Licensee will ensure that " No Smoking -Oxygen in Use " signs are posted so everyone is aware that there is oxygen in use at the facility.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)(6)
- Regulation authority
- CCR
What the official deficiency says
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. 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 as it was observed that there is no hospice care plan or the specific services that will be provided in Resident #4's Hospice file in which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will contact the hospice agency for Resident #4 and obtain the complete care plan, the required training needed for the care of Resident #4 and the specifc services to be provided to Resident #4 by 9/4/25. Provide evidence that the care plan, required training and services to be provided has been obtained.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(3)(b)
- Regulation authority
- CCR
What the official deficiency says
87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (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 was not met as evidenced by: 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 bedroom #2 and bedroom #3 do not have chairs and bedroom #2 does not have any dressers, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction Licensee will ensure that all the required Title 22 furniture is provided to all residents. Licensee will purchase 2 chairs each for bedroom #2 and bedroom #3 and dressers for bedroom #2. The dressers must be 8 cubic feet for each resident. Proivide evidence to the Department by 9/4/25.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as it was observed that the dining room table had only 4 dining chairs for use and 2 dining room chairs were stored in the garage. One of the dining room chairs stored in the garage was broken which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction Licensee will ensure that the appropriate furniture is provided in the quantity for the licensed capacity for residents use at all times. Licensee will repair or replace the broken chair and make it available for residents' use by 9/4/25.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(b)
- Regulation authority
- CCR
What the official deficiency says
87465 Incidental Medical and Dental Care (b) 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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview with the Administrator, the licensee did not comply with the section cited above per review of Resident #4 medications, it was noted that Resident #4 was prescribed Ambien as needed on 7/16/25 but it was being dispensed daily as a routine medication without a change order which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction Licensee will contact the prescribing physician and get clarification on the correct dose and frequency that the PRN Ambien is to be dispensed on a script and submit a copy to the Department by 9/4/25.
Plan of correction recorded
Correction not verified in available records
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 3 out of 4 counts as Resident #1(last appraiisal 2/20/24), Resident #2 (last appraisal 9/10/23)and Resident #3 (last appraisal 5/24/24 have not beein reappraised since the last noted date, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/04/2025 Plan of Correction The Licensee will schedule an appointment with Resident #1, Resident #2 and Resident #3 families and the residents' themselves to conduct a reappraisal and update their care plan based on any changes in condition or any identified need by 9/4/25. Licensee will provide evidence that the reappraisal has been completed by 9/4/25.
Plan of correction recorded
Correction not verified in available records
Inspection
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(f)(1)
- Regulation authority
- CCR
What the official deficiency says
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as an unsecured box cutter was observed in an unlocked closet which posed an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 08/30/2024 Plan of Correction Administrator secured the box cutter at the time of the visit. POC cleared.
Official record says corrected or clearedOn or before Aug 30, 2024
Plan of correction recorded
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(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 Based on record review, the licensee did not comply with the section cited above as one (1) staff member lacked the required 20 hour annual training which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/06/2024 Plan of Correction Administrator will submit the following to CCL no later than POC due date. Proof of completed trainings, proof of completed in-service trainings, or proof of enrollment in required trainings for the identified employee.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 as two (2) of two (2) resident centrally stored medication record sheets were missing perscribed medications which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 09/06/2024 Plan of Correction Administrator will submit proof of updated centrally stored medication record sheets for the two (2) identified residents to CCL no later than POC due date.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(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 Based on observation and record review, the licensee did not comply with the section cited above as one (1) resident has full bed rails but does not have a physician's order for them which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/06/2024 Plan of Correction Administrator will submit either, proof of physician's orders for full bed rails or proof that full bed rails have been removed to CCL no later than POC due date.
Plan of correction recorded
Correction not verified in available records
Dementia careType B
- Official classification
- Type B
- Official code
- 87705(c)(5)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 as one (1) resident who is diagnosed with dementia lacked a physician's report dated within the last year which poses a potential health risk to persons in care.
Official plan of correction
POC Due Date: 09/06/2024 Plan of Correction Administrator will submit proof of an updated physician''s report for the identified resident to CCL no later than POC due date.
Plan of correction recorded
Correction not verified in available records
Dementia careType B
- Official classification
- Type B
- Official code
- 87705(g)
- Regulation authority
- CCR
What the official deficiency says
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as one (1) resident was identified to be at risk if allowed access to personal hygiene items and personal hygiene items were observed unsecured throughout the facility which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 09/06/2024 Plan of Correction Licensee will submit proof to CCL no later than POC due date that all hygiene items throughout the facility have been appropriately secured.
Plan of correction recorded
Correction not verified in available records
Inspection
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(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 Based on observation, the licensee did not comply with the section cited above per review of medications, HumulinN prescribed for Resident #4 was stored on the refrigerator door in a zip lock bag which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/01/2023 Plan of Correction Licensee will immediately take steps to ensure that the Humlin N is locked and secured so that it is inaccessible to the other residents in care by 9/1/23
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. 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 information provided by the Administrator, one resident has dementia and one is able to make own decision. However, the physician has not been contacted to make a final decision if either resident is or is not able to make their own decision which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction LIcensee will contact the prescribing doctors to obtain PRN Authorization Letters for all residents who are prescribed PRN medications and maintain in the residents' file
Plan of correction recorded
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(d)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above since the Administrator has not established with the prescribing physician if Resident #5 is able to make own decision to request the medications other than the licensee's own observation which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction Licensee will contact the doctor for Resident #2 and Resident #5 each time the PRN medications are needed to obtain instructions from the physician, based on the the symptoms observed, whether the medication is to be dispensed until the PRN Authorizations can be obtained and a determination is made whether each resident can or cannot make their own decision for the PRN Medicatins by 9/7/23
Plan of correction recorded
Correction not verified in available records
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(e)
- Regulation authority
- CCR
What the official deficiency says
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the facility does not have any physician's order on file for any of the centrally stored medications which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction Licensee will contact the prescribing doctors for the centrally stored medications and obtain copies of the physician's orders and maintain in the residents' files by 9/7/23
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87467(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 all 5 resident files reviewed. Resident #1 through Resident #4 have not had a annual reappraisal review since as far back as 2013 and 2018, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/14/2023 Plan of Correction Licensee will schedule a meeting with the resident and responsible parties to review and revised the written record by 9/14/23
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- 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 per information provided by the Administrator that the facility has internet but does not have any computers, tablets, smart phone or any other devices available to dedicate for the residents' use. Only one resident has own computer which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction LIcensee will submit a plan of action as to how the facility will provide a dedicated device that can support real-time interactive applicatins for residents use by 9/7/23
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- 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 and does not have a policy in place to address how the facility will make a device accessible to the residents in care to have discussions of personal or confidential information which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction Licensee will come up with a tentative policy as to how the computer, tablet or other device will be made accessible to the residents for personal discussions or confidential information by 9/7/23
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- 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 as the facility does not have a policy in place as to how they will make the computer, tablet or other devices accessible among the 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: 09/07/2023 Plan of Correction Licensee will include in the plan of action and tentative plan related to providing a computer, tablet or any other device as to how the device will be shared or made accessible to the residents during reasonable hours by 9/7/23
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited per review of the MAR logs reviewed. The Licensee is inconsistent about updating the MAR log when medications are dispensed. Per review of the August 2023 MAR log, medications dispensed from 8/24/23 through 8/31/23 were not updated. Also, MAR logs from March 22, 2022 through July 2023 were not maintained,which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction Licensee will provide LPA Yee with a plan of action that will ensure that dispensed medications are updated daily on the MAR log and how MAR logs will be used 12 months a year to document dispensed medications by 9/7/23
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(3)
- Regulation authority
- CCR
What the official deficiency says
(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 Based on record review and interviews, the licensee did not comply with the secction cited above per information provided, the facility does not document any dates of contact made with the physician, does not document the physician's instructions, the date the PRN's were dispensed, the dosage or the results of the dosage, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2023 Plan of Correction The Licensee will come up with a plan as to how they will document the date of contact with the physician, the instructions provided, the date and time dosage was dispensed, the reactions/result of the medications and maintain it in the residents' file
Plan of correction recorded
Correction not verified in available records
Inspection
Facility condition and maintenanceType B
- 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 LPAs observation, the licensee did not comply with the section cited above as resident restrooms were observed not clean, or sanitary around the sink areas, which poses a potential health and safety risk to residents in care.
Official plan of correction
POC Due Date: 07/25/2022 Plan of Correction The Licensee has agreed to do the following: 1.Submit photos of clean, and sanitary facility restrooms to CCL by 7/25/22.
Plan of correction recorded
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
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