Inspection visit

Follow-up on correctionsApril 21, 2021

PEARL OF WEST HILLS, INCLicense 1976098899 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Virtual Case Management Deficiencies visit due to deficiencies observed during the investigation of complaint control 31-AS-20210416135138 on 4/20/2021. Upon entrance to the facility on 4/20/2021 LPA observed a key lock inside the facility entrance door. At 2:40 pm LPA took a photo of the door and spoke with the administrator who stated that she has to lock the door to prevent Resident 1 (R1) from leaving the facility. At 3:18 pm LPA also observed the back gate of the property also with a key lock installed from inside the backyard. LPA informed administrator that the locks needed to be removed/replaced immediately but no later than today 4/21/2021. On 4/20/2021 from 2:15 pm to 2:30 LPA conducted a tour of the facility with the administrator. From 2:30 to 4:30 LPA conducted interview with administrator and reviewed files for Resident 1 (R1) and Resident 2 (R2). While reviewing the residents files LPA observed that files for both residents are incomplete. Resident files were missing the following documents: Physicians report with TB test, (R1) Current Centrally stored medication and destruction log. (R1 and R2) Admission agreement, (R1 and R2) Pre-Admission appraisal(R1) functional Capabilities (R1) Identifications and emergency information sheet (R1 and R2) Licensee did not have hospice care plan (R1) Order for full rails. (R1) No PRN administration logs used for R1 and R2 Today 4/21/2021 at 3:00 pm LPA called the facility to speak with administrator. Phone was answered by an unknown individual who gave the phone to administrator. LPA asked administrator about the individual who answered the phone. LPA was informed that the person was a volunteer, who the administrator was trying out to see if she can hire. At 3:05 LPA called administrator via FaceTime. When administrator answered the phone the "volunteer" was washing dishes. LPA informed administrator that all staff are required to have criminal record clearance and the clearance has to be transferred to the facility prior to volunteering or working at the facility. LPA asked administrator to show her the front doors. Administrator informed LPA that the locks have not been removed and that a handyman would be coming 10:00 am tomorrow. At 3:52 pm LPA received a call from the administrator who stated that she scheduled a handyman to replace the locks 6:00 pm today. Exit interview was conducted via telephone and copy of report with citations were emailed to administrator for signature. .

Citations

9 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87465(h)(6)Type B
87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...This requirement is not met as evidenced by: Based on observation, record review and interviews, licensee failed to have a complete centrally stored medication records for 2 out of 2 resident (R1, R2, ) which poses a potential health and safety risk to residents in care.
87633(b)Type B
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:This requirement is not met as evidenced by: Based on 4/20/2021 record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 1 out of 1 resident who is currently receiving hospice services which poses a potential health, safety or personal rights risk to person in care
87355(e)(2)Type A
(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: Based on record review the licensee did not comply with the section cited above by not transferring criminal record clearance for staff 1 (S1) which poses an immediate health, safety or personal rights risk to persons in care.
87458(b)(1)Type B
87458(b)(1) Medical Assessment. The medical assessment, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE This requirement is not met as evidenced by:Based on record review conducted on 4/21/2021, licensee failed to obtain medical assessment and TB test result for 1 out 2 residents (R1) which poses a potential health risk to resident in care.
87468.1(a)(c)Type A
Personal Rights of Residents....to leave or depart the facility at any time....This requirement was not met as evidenced by: Based on observations made and interviews with licensee/administrator which revealed that lhe licensee locks with a key lock inside the facility to prevent resident from wondering out which poses an immediate health and safety and personal rights violation to residents in care.
87506(b)Type B
(b) Each resident's record shall contain at least the following information:This requirement is not met as evidenced by: Based on 4/20/2020 record review, the licensee did not comply with the section cited above by not having a complete file for 2 out of 2 residents which poses a potential health, safety or personal rights risk to persons in care.
87465(C3)(D3)Type B
(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: Based on records reviewed and interview conducted on 4/21/2021 which revealed that licensee/administrator does not use PRN administration log which poses a potential health and safety and personal rights risk to residents in care
87608(a)(5)(B)Type A
(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: Based on 4/20/2021 observation and interview, the licensee did not comply with the section cited above by utilizing full bed rails for 1 out of 2 residents, (R1) who is on hospice however the licensee does not have a hospice care plan that identifies the need for the full rails which poses an immediate health, safety & personal rights risk to R1.
87705(l)(5)Type A
The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates:(2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not being met as evidenced by LPA observation and administrator confirmation while conducting a tour of the facility and interview conducted with administrator on 4/20/21 which revealed that the front door and back gate door are locked and can only be opened with a key which poses an immediate health and safety and personal rights violation to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 21, 2021 inspection of PEARL OF WEST HILLS, INC?

This was a other inspection of PEARL OF WEST HILLS, INC on April 21, 2021. 9 citations were issued: 4 Type A (serious) and 5 Type B.

Were any citations issued to PEARL OF WEST HILLS, INC on April 21, 2021?

Yes, 9 citations were issued (4 Type A, 5 Type B). The first citation was for: "87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrall..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·April 21, 2021