Land Park Place

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 7/6/23 at 12:00PM. Administrator certificates expires 2/20/2025. License fees current. LPA met with Yacub Lucas and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 6 may receive hospice services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents participating in a group activity during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a pull alarm system. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Jul 6, 2023

Allegation investigated: Staff did not provide a care plan for resident upon admissions Staff did not replace resident's smoke alarm. Facility kitchen floor is in disrepair. Facility ceiling has water damage.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigations of the above-mentioned allegations. LPA met with caregiver Verny Roring and stated the purpose for today's visit. Regarding allegation, “Staff did not replace resident's smoke alarm”, through interviews, LPA obtained information that the smoke detector was not functioning properly during the time the resident resided in the room. Licensee stated the detectors’ battery was replaced only not hard wired until after the resident relocated. LPA received confirmation from City Fire Department that the detector is functioning properly in accordance with Fire Code which was checked once they received a complaint in February. Although, the detector is now working properly it was not correctly installed while resident was residing in the facility. Substantiated Regarding allegation, “Facility ceiling has water damage” through interviews and observation, LPA found that there are spots in the ceiling of one of the residents rooms that appears to be water damage. Regarding allegation, “Staff did not provide a care plan for resident upon admission”, LPA obtained information that resident #1 (R1) and/or R1’s Responsible Party signed documents that were incomplete upon admission. Administrator stated that an assessment would be put into place after getting to know the resident. LPA observed the Admission Agreement that shows areas highlighted for signatures and initials, all of which are completed and signed by Licensee and Responsible Party on 2/5/23. However, the Identification and Emergency Information form (LIC601) was not completed, dated or signed. Additionally, Appraisal/Needs and Services Plan (LIC625) was observed to be incomplete but signed and dated which confirms the allegation. Regarding allegation, “Facility kitchen floor is in disrepair”, through interviews and observation, Administrator and staff all confirmed that the kitchen floor was not leveled, and the laminate tiles were not properly attached to the floor which was a tripping hazard. Based on interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. Additionally, Based on fire clearance deficiency not corrected prior to resident relocating, you are hereby assessed an Immediate civil penalty in the amount of $150.00. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, May 17, 2023 · control 27-AS-20230216101319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: May 17, 2023

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: The Licensee stated to LPA that the battery was changed but not hard wired until later. Based on Licensee did not ensure the smoke detector was working properly during the time resident resided in the home. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee replaced the smoke detector’s battery and connected the hard wire after the resident relocated. You are hereby assessed an Immediate civil penalty in the amount of $150.00. Plan of Correction cleared prior to visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 17, 2023

Maintenance and Operation The facility shall be…in good repair at all times...for the safety and well-being of residents, employees and visitors This requirement is not met as evidenced by: The ceiling has visible spots. Based on Licensee did not fix the ceiling and/or roof as there appear to be water damage. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee shall submit a plan with a due date of when the ceiling and/or roof will be completely fixed along with a mold inspection. Plan of Correction cleared prior to visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8007(b) · Plan of correction due date: May 19, 2023

87506(a)(b)(1-17)(A-F) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Each resident’s record shall contain at least the following information: This requirement is not met as evidenced by: The required documents were not completed timely. Based on Licensee did not ensure resident records were completed prior to signature and/or admittance. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee shall submit a letter stating all required documents will be completed timely. To be submitted by Plan of Correction due date via fax.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: May 19, 2023

Maintenance and Operation …Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Administrator stated the kitchen floor was not leveled, and the laminate tiles were not properly attached to the floor Based on Licensee did not ensure the floor was repaired timely for resident safety This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee replaced the kitchen floor tiles to level out the floor. Plan of Correction cleared prior to visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/20/22 at 3:00PM. Administrator certificates expires 2/20/2023. LPA met with Erlinda Sembrano, Caregiver and stated the purpose of todays visit. The facility is licensed for a capacity of 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents participating in a group activity during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 78*F which is within the required range of 68-85*F. The hot water temperature was measured at 115.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a pull alarm system. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, May 20, 2022