VCT Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was allowed entry by Teresita Pugado, Caregiver and explained the purpose of today's visit. At 4:10pm, Administrator Ronald Barit arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is no visitor sign-in station. The facility has submitted an Infection Control Plan on 6/20/2022. The facility has also submitted a COVID-19 Mitigation Plan. Facility does not have COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Administrator will submit an updated Infection Control Plan to Licensing as required. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 4/19/2024. Surety bond of $4,000.00 is current and will expire on 5/02/2026. Care and supervision to meet the residents needs was observed. Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single storey home located in a residential neighborhood. It is licensed for 6 non ambulatory residents age 60 and above. Rooms #1, 2, 3 & 4 are cleared for 1 non ambulatory each. Room #5 is cleared for 2 non ambulatory and bedridden fire clearance. It consists of five (5) resident rooms, (2) of the rooms are divided by curtains, one (1) staff bedroom, three (3) full bathrooms, living room, kitchen, dining room, carport and backyard with covered patio. At 4:02pm, water temperature readings measured above the required 105 - 120 degrees Fahrenheit. Water temperature read at 122.5 degrees F bathroom #1, 125.9 degrees F bathroom #2 and 126.8 degrees F in bathroom #3. At 5pm, LPA re-measured the water temperature readings and measured between 109.1-115.1 degrees F which is within Title 22 Regulations requirement. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. Cameras are operational and located in the front and side of the house. The facility has (1) fire extinguisher located between the kitchen and dining room and was last serviced on 01/15/2023. Cleaning supplies and toxic substances are inaccessible to clients. *****CONTINUED ON LIC809-C***** Staffing: A total of three (3) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance and have the required training and associated to the facility. One (1) of the staff members did not have valid First Aid training certificate and last training expired on 4/20/2023. Personnel Records-Training: Administrator certificate expires 2/19/2024. Administrator stated that the change of Administrator request will be sent to the Woodland Hills Office. Staff have criminal background clearance and training. Two (2) staff files were reviewed. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: A total of three (3) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, Individual Service Plans, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. Resident Rights-Information: Resident personal rights are posted. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Facility has an activity calendar provided to the residents. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. Records of resident Appraisal and Needs services plans are part of Emergency training. Fire Drill was last conducted on 11/19/2020. Pursuant to Title 22, deficiency was cited on the attached 809D and Technical Assistance were issued. An exit interview was conducted, and a copy of this report was provided to Ronald Barit, Administrator.the state’s words, verbatim · CDSS document, Jul 22, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Residents' mattress is in disrepair. Resident is not provide proper lighting. Facility's electrical wiring is in disrepair.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the administrator, Victoria Torres, and explained the reason for the visit. --- Residents' mattress is in disrepair. It was alleged that the mattresses in bedrooms #2 (two) and #3 (three) are in disrepair and will need to be replaced. To investigate this allegation, on 01/23/2023, LPA made observations during a physical plant tour at around 9:30 AM, interviewed staff from around 12:00 PM – 1:00PM and interviewed residents from around 1:30 PM – 2:00 PM. During the physical plant tour, LPA uncovered and observed mattresses in bedrooms #2 (two) and #3 (three) but did not find any disrepair. (Cont. on LIC 9099-C) Unsubstantiated LPA checked remaining mattresses and did not find any disrepair. During interviews with staff, Staff #1 (S1) stated that the mattresses were not replaced, felt the mattresses were fine, but that they ordered new ones which will be delivered by tomorrow (01/24/2023). Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. --- Resident is not provide proper lighting. It was alleged that the lamps in the resident's bedrooms are all unplugged and also there is no light provided in the resident's closet. To investigate this allegation, on 01/23/2023, LPA made observations during a physical plant tour at around 9:30 AM, interviewed staff from around 12:00 PM – 1:00PM and interviewed residents from around 1:30 PM – 2:00 PM. During the physical plant tour, LPA observed adequate ceiling lights in all bedrooms and a lamp in each room which were plugged in and operational. Each resident’s closet is located in their bedrooms. During interviews with staff, Staff #1 (S1) stated that all the lights work and some of the residents don’t want the lamp, so they unplug it. During interviews with residents, they all stated that they don’t have any issues with the amount of lighting in the room and do not feel any restrictions regarding lamp usage. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. --- Facility's electrical wiring is in disrepair. It was alleged that the electrical supply wires may not conform to Los Angeles Building and Safety electrical guidelines. To investigate this allegation, on 01/23/2023, LPA made observations during a physical plant tour at around 9:30 AM, interviewed staff from around 12:00 PM – 1:00PM and interviewed residents from around 1:30 PM – 2:00 PM. (Cont. on LIC 9099-C) During the physical plant tour, LPA observed dated electrical work that may or may not conform to current Building and Safety standards. LPA observed coaxial and electrical cables running throughout the facility and through walls. LPA did not observe any exposed copper wires. During interviews with staff, Staff #1 (S1) stated that it has been like this since purchased but that an electrician will be coming tomorrow (01/24/2023) to make the necessary adjustments to bring everything up to code. During interviews with residents, they all stated that they don’t have any issues with the electrical wiring. Based on observations and interviews, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. Other health and safety hazards noted during the visit which will be addressed on separate Case Management LIC 809. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 23, 2023 · control 31-AS-20230118161528

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management Visit in conjunction with an initial complaint visit (Complaint Control Number: 20230118161528). LPA met with the administrator, Victoria Torres, and explained the reason for the visit. During a physical plant tour, LPA discovered conflicting facility layouts that do not conform with the Department’s approved facility sketch. The first conflict was discovered in the room labeled “Staff Room” which was approved as one room with a window and closet, however, facility built an unapproved floor-to-ceiling wall which runs down the middle of the room and the only window (wall runs the length of the room and each side of the room shares a portion of one window). The room also has an unapproved interior door to gain access to the right side of the Staff Room (essentially, a room within a room). The other conflict was discovered in the room labeled “Room #5” (five). This room also has an unapproved wall that runs the length of the room, but unlike the Staff Room, it has individual entry doors and a full window in each room. The facility labeled the doors #5 and #6. Furthermore, in Room #4 (four), LPA discovered electrical wires running from the outlet through the bedroom wall into the closet, then runs along the floor, from one side of the closet door to the other, then through the interior of the closet wall, and out through the bedroom wall to power a wall mounted television. These wires pose a potential tripping hazard. LPA also discovered that the carbon monoxide detector in the dining/kitchen area is not operational. Smoke detectors in the hallways are old and also not operational. Under Title 22 regulations, the following citations are issued and recorded on LIC 809-D. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Jan 30, 2023

Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met, evidenced by:Based on LPA observations the facility has been altered and the facility did not provide the building permits or new facility sketch to LPA for Staff Room and Room #5 division/partitions. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: Administrator is to send picture proof of the removed walls to the LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jan 30, 2023

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPA's observations, bedroom #4 has electrical wires on the closet floor which poses a potential tripping hazard to residents and poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2023

Plan of correction: Administrator is to send picture proof of the removed wires to the LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an Inspection Control Annual. LPA was greeted by facility staff and his temperature was taken and COVID-19 questions were asked before being allowed entry. LPA was able to briefly tour the inside and outside of the facility. There are 6 bedrooms designated for residents use. The smoke alarms and carbon monoxide detectors were tested and all functioned properly. The fire extinguisher was last serviced on 2/21/2022 and appeared functional. The facility is currently following their approved mitigation plan. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jun 17, 2022

Type of visit: Required - 1 Year

A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Ronald Barit. Purpose of visit was stated. LPA observed that all six (6) residents were at the facility during visit. This facility is vendored by North Los Angeles Regional Center. A tour of the physical plant was conducted at 12:35 AM and the following were noted: The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear mask and must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by the staff upon entry. All staff were observed to be wearing mask. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room. The facility has seven (7) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is licensed to care for non-ambulatory clients, two (2) of which may be bedridden. (continued on LIC 809-C) Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detector and Carbon Monoxide detector are hardwired and interconnected and are tested and observed to be operational. Fire extinguisher was observed to be full and last serviced on 02/21/22. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. There is a locked shed at the backyard being used as a storage facility. The car port is covered and currently being used as laundry area. Laundry soap, cleaning agents and other toxins are kept in a locked cabinet in the laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are stored at the kitchen drawer and was observed to be secured, locked and inaccessible to residents. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene products on each bathroom which is provided by the licensee. Staff Rooms: Staff room was locked. No medication was observed in the staff room. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet and shower. The hot water temperature was measured at a range of 115.9°F to 117.8°F. There is sufficient supply of clean linen available in stock at the cabinet. Medications: LPA observed medication in the medication room to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. Complete first aid kit is readily available. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Feb 23, 2022