Encino Gardens

Accountability of Licensee Governing Body. The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation... welfare of the individuals it serves.This requirement is not met as evidenced by: the licensee failed to notify the Department at least 30 days prior to the sale/transfer of the facility, as required by Title 22 which poses a potential risk to residents in care

(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Based on the observation and record review, the licensee did not comply with the section cited above in several (areas) of the facility which poses an immediate health, safety or personal rights risk to persons in care.

(a) Each facility shall have and maintain a current, written definitive plan of operation...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 as evidenced by: Based on the observation, interview and record review, the licensee did not comply with the section cited above in submitting a written declaration stating that there will be structural changes to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

(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 the observations, the licensee did not comply with the section cited above in the areas of construction being clean, safe and sanitary for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Prior to construction or alterations, all facilities shall obtain a building permit.This requirement is not met as evidenced by: Based on the observation, interview and record review, the licensee did not comply with the section cited above in structural changes which poses/posed a potential health, safety or personal rights risk to persons in care.

Criminal Clearance 87355(e)(1) 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 This requirement is not met as evidenced by: Licensee failed to obtain criminal clearance/background association for an indvidual that is currently working as a staff which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility..This requirement is not met as evidenced by: Licensee/Administrator failed to notify Community Care Licensing Department of any changes of ownership/administration changes which poses an Immediate Health, Safety or Personal Rights risks to persons in care

(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change..(B) The conditions under which a licensee may increase or change rates shall be specified in the admission agreement..This requirement is not met by: Based on the observation and record review of the facilities' admission agreement page 71, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Based on (record review, the licensee did not comply with the section cited above in 1 out of 2 staff files have expired or missing CPR/First aid certificates which poses an immediate health, safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature… This requirement is not met as evidenced by;Based on evidence provided to licensing from other sources, the licensee did not ensure that the resident was free from punishment, humiliation, abuse and intimidation which poses an immediate health, safety and personal rights risk to residents in care.