Pearl of West Hills, Inc

Based on observations and interviews, the licensee did not comply with the section cited above by not ensuring a qualified administrator or designee was responsible for facility operations today which poses an immediate health, safety or personal rights risk to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above in allowing Staff #1 (S1) to care for residets without documented training which poses an immediate health, safety or personal rights risk to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above in exceeding the facility's fire clearance by placing two (02) bedridden residents in Bedroom #4 which poses an immediate health, safety or personal rights risk to persons in care.

Based on interviews, the licensee did not comply with the section cited above in two (02) out of three (03) residents using full bed rails without physician orders which poses an immediate health, safety or personal rights risk to persons in care.

Based on observations and interviews, the licensee did not comply with the section cited above in not providing the staff file of Staff #1 (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observations, the licensee did not comply with the section cited above in one expired fire extinguisher in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above in Staff #1 (S1) caring for residents without a criminal background clearance associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observations, the licensee did not comply with the section cited above in two (02) out of three (03) residents with full bed rails without a hospice care plan 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 two (02) out of three (03) resident medical assessments which poses/posed a potential 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 one (01) out of one (01) which poses/posed a potential 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 one (01) out of two (02) employees which poses/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 two (02) out of three (03) water faucets 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 one (01) out of two (02) employees which poses/posed a potential health, safety or personal rights risk to persons in care.

Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health & Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following: Importance and techniques of personal care services, including but not limited to,..feeding...This requirement is not met as evidenced by; Based on interviews & record review, staff do not have client specific training for feeding assistance & aspiration pneumonia which poses an immediate health, safety and personal rights risk to resident in care.

Based on observation it was observed that resident #4 had a full bed rail and is not on hospice. This is an immediate health and safety risk to residents in care.

(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 DepartmentrThis requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not ensuring staff 1 (S1) obtained criminal record clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.

Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.This requirement was not met as evidenced by: Based on interviews conducted residents did not have planned activities which posed a personal rights violation to residents in care.

Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met as evidenced by: Based on interviews conducted facility did not have enough staff to meet all resident needs.This poses a potential health and safety risk to residents in care.

87406 Administrator Certification Requirements (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder hascomplied with all renewal requirements.This requirement is not met as evidenced by: Based on review of records and interview with licensee which revealed the Licensees Administrator Certificate expired 08/08/2020 and the Administrator has not taken the required classes to renew the required Administrator Certificate which poses an immediate health, safety and personal rights risk to residents in care.

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement was not met as evidenced by: Based on interview and attempted telephone calls to the facility the licensee did not comply with the cited section by not ensuring that a telephone service is available on the premises at all times which poses an immediate personal rights violation to R1.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidenced by: Based on interview the licensee did not comply with the cited sections by allowing R1 to have personal/confidential phone calls with family which posed an immediate personal rightsviolation to R1.

(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on medication count the licensee did not comply with the section cited by not assisting R1 and R2 with self administered medications as prescribed which posed/poses an immediate health and safety and personal right risk to residents in care.

Incidental Medical... A plan for incidental medical...shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted with administrator and R1 that revealed that the administrator did not receive medical attention in a timely manner which posed an Incidental Medical...violation to resident(s) in care.

(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) to this facility prior to employment which poses an immediate health, safety or personal rights risk to persons in care.

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 shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date & time the PRN medication was taken, the dosage taken, & the resident's response.This requirement was not met as evidenced by: Based on records review and interview the licensee did not comply with the cited sections by not documenting when PRN medications were administered to R1. Which posed an

(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 resident's 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 was not met as evidenced by: Based on hospital records review the licensee did not comply with the section cited above by not having a signed written order from a physician for the medication Geodon given to resident 1 which posed an immediate health, safety and personal rights risk to R1.

(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 shall be permitted to assist the resident with self-administration, provided the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on medication review the licensee did not comply with the cited sections by not giving medications per the physicians directions which posed an immediate health, safety and personal rights risk to R1.

87406 Administrator Certification Requirements (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder hascomplied with all renewal requirements.This requirement is not met as evidenced by: Based on review of records and interview with licensee which revealed the Licensees Administrator Certificate expired 08/08/2020 and the Administrator has not taken the required classes to renew the required Administrator Certificate which poses an immediate health, safety and personal rights risk to residents in care.

Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: Based on interviews conducted staff were not checking all visitors temperatures upon entry to the facility which poses an immediate health and safety risk to residents in care.

Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.This requirement was not met as evidenced by: Based on interviews conducted facility does not have any planned activities for residents.

Personal Rights of Residents in All Facilities-To wear their own clothes; to keep and use their own personal possessions.This requirement was not met as evidenced by: Based on interviews conducted it was observed and admitted to by the administrator that R1 was not able to wear or have access to their own clothes which is a violation of residents personal rights.

Personal Rights of Residents in All Facilities-To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.This requirement was not met as evidenced by: Based on interviews conducted residents were not able to leave the facility at anytime. This poses a potential personal rights violation to residents in care.

Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Based on interviews conducted it was revealed that R1 was yelled at by the facility administrator which posed a personal rights violation to residents in care.

Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

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.

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.

(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.

(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

(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.

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.

(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.

(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

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.