Burbank Hills Comfort Living

Based on observation, the licensee did not comply with the section cited above in having a torn window screen, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in having sharp objects accessable to residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above in not having carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in providing an updated facility sketch to CCLD with changes regarding room changes which posed a potential health, safety or personal rights risk to persons in care.

Based on interview with staff and record review, the licensee did not comply with the section cited above in regarding to death report of one resident, which posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in regards to a broken shed door, ceiling damages, air filter dust, which poses a potential health, safety or personal rights risk to persons in care.

Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the 87457 Pre admission Appraisal- General: prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have preplacement appraisal and functional capacities in resident files, which poses an immediate health, safety or personal rights risk to persons in care.

87458 Medical Assessment:Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physicians report was blank and not update, which poses an immediate health, safety, or personal rights risk to persons in care.

Incidential Medical & Dental Care: 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 residents file, and a label on the medication. Both the physician's order and the label shall contain at least all the following information This requirement is not met by evidence of: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have physicians’ orders in resident files, which poses an immediate health, safety, or personal rights risk to persons in care.

The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met by evidence by: During LPAs tour facility staff had left cleaning supplies in hall closet.

87412 Personnel Records:The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: This requirement is not met by evidence by: Based- on record review, the licensee did not comply with the section cited above in 2 out of 2 Staff employee rights was not in their files, which poses an immediate health, safety, or personal rights risk to persons in care.

87707 Training Requirments: Direct care staff shall complete at least eight hours of in-service training about serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. A minimum of two of the following training topics shall be covered annually, and all topics shall be covered within a three-year period… This requirement is not met by evidence by: During record review on 3/8/22 and todays visit LPAs observe no staff training.

87208- Plan of Operation:Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met by evidence by: Administrator will ensure to submit a change of operation to CCLD and review regulation 87208(a) to ensure compliance in the future.

87355 Crimanal Record Clearance(e)All individuals subject to a criminal record review pursant to Health and safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the department or This requirement is not met by evidence by: Based on record review on 3/8/2022, the licensee did not comply with the section cited above in 1 out of 1 Staff is not fingerprinted, associated or have background check clearance, which poses an immediate health, safety, or personal rights risk to persons in care.

87412 Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: 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 by evidence by: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff Administrator Certification expired 3/31/21.

Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physcians report was blank and not update, which poses an immediate health, safety or personal rights risk to persons in care.

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87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: during LPAs file review, LPA observed no staff to have current 1st Aid Training. This poses an immediate health and safety risk to residents in care

87457 Pre-Admission Appraisal - General(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1, R2, and R5 did not have Pre-Admission Appraisals completed before moving in. This poses a potential health and safety risk to residents in care.

87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1 and R5 do not have medical assessments in their files. This poses a potential health and safety risk to residents in care.

87463 Reappraisals(c) 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, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: during LPAs review of residents files, LPA observed R3 and R4 to have appraisals which have not been updated in the last 12 months as required. This poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (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: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 to have medications prepoured in a 7-day pill container but no other medications on hand. Administrator told LPA that R3 does not take medications but could not provide discontinue orders for the prescribed medications on R3's LIC 602. R3's medications are not being given per physician orders. This poses an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (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 residents 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: during LPAs medication review, LPA observed R4 to have PRNs and Vitamins which did not have physician orders. LPA reviewed R4s 602 and R4 is unable to administer own PRN medications. This poses an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: during LPAs medication review, LPA observed R3 and R4 to have medications which were prepoured for 7 days in a morning/afternoon/evening in a 7-day pill container. Administrator was unable to show LPA original containers as they were stored in the garage and the garage was locked and unable to be accessed. This poses an immediate health and safety risk to residents in care.

87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice.This requirement is not met as evidenced by: during LPAs tour of facility with administrator, LPA could not inspect garage outside because it was locked and administrator did not have a key. This poses an immediate health and safety risk to residents in care.

87355 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department orThis requirement is not met as evidenced by: when LPA arrived S3 was present at the facility and interacting with residents, S3 does not have criminal record clearance. Administrator told LPA that S3 has been volunteering in the facility for about a month and that she wanted to see how she did before she hired her. This poses an immediate health and safety risk to residents in care.

87355 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) orThis requirement is not met as evidenced by: upon LPAs arrival, LPA observed S2 to be present at the facility. LPA reviewed S2's file and did not observe a LIC 9182 for criminal record clearance transfer request to the facility. Administrator was unable to provide proof of transfer request. This poses an immediate health and safety risk to residents in care.

§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision This requirement is not met as evidenced by: during LPAs file review LPA observed the only staff training completed in 2018 was dementia training, the other topics had not been covered. This poses a potential health and safety risk to residents in care.

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...] This requirement is not met as evidenced by: during LPAs inspection, LPA observed only administrator was able to assist all residents and prepare food for lunch. During file review, LPA observed the administrator is the only person associated to the facility and able to work. This poses an immediate health and safety risk to residents in care.