Inspection visit

Follow-up on correctionsMarch 27, 2024

EMBRACING SENIORSLicense 5658024644 citations on this visit

4 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Case Management Deficiency visit in conjunction with an initial 10-day complaint visit (CC # 29-AS-20230523101459). LPA met with staff Regie Dulay. Staff contacted Licensee/Administrator and LPA reviewed the report with Licensee. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. The facility failed to seek medical attention in a timely manner for Resident #1 (R1). During interviews, the staff and administrator acknowledged R1’s pressure injuries progressively worsened, and they did not seek medical attention. Staff and administrator continuously stated the prescribed ointment was not received; however, staff and administrator failed to seek medical attention and inform a medical professional that the discharge care treatment was not being done. The facility failed to report R1’s fall incident in the bathroom to Community Care Licensing (CCL). The fall resulted in R1 having bruises on forehead and lower extremities. It was noted in the 05/22/2023, Adventist Health Simi Valley medical records, that R1 had several areas of bruising to the forehead and lower extremities. The evaluation noted the bruising was consistent with a recent fall. The 05/12/2023 Special Incident Report (SIR) noting a “rash” to R1’s left shoulder and hip requiring a doctor visit, diagnosed as pressure injuries, was dated 05/25/2023, more than 7 days after the incident date. There is no evidence or confirmation that the SIR was submitted to CCL. R1’s hospice notification, dated 05/25/2023, was also not received by CCL. R1’s Physician Report, dated 02/27/2023, lists R1 as not on hospice and not able to perform any activities of daily living, which is considered a prohibited health condition. R1 was placed on hospice care on 05/24/2023. Citations issued, exit interview, appeal rights given.

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.

87211(a)(1)(B)Type B
(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... within seven days of the occurrence of any of the events specified in.....(B) Any serious injury....while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. No evidence or confirmation that the licensee submitted the 5/12/2023 SIR, dated 05/25/2023, to CCL. Licensee did not submit an SIR for R1’s fall , which posed a potential health and safety risk to residents in care.
87465(a)(1)Type A
(a) A plan for incidental medical and dental care shall be developed by facility. The plan shall encourage routine medical and dental care.... (1) The licensee shall arrange.....for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee did not seek medical attention when R1’s pressure injuries progressively worsened, which posed an immediate health and safety risk to residents in care.
87615(a)(5)Type A
(a) Persons who require health services for or have a health condition including, but not limited to, those specified....(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. The licensee retained R1 who depended on others to perform all activities of daily living, which posed an immediate health and safety risk to residents in care.
87632(d)(2)Type B
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver....... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally Ill resident.....This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There is no evidence/confirmation that the licensee submitted a notification for R1’s 05/24/2023 initiation of hospice care services, which posed a potential health and safety risk to residents in care.
1569.695(d)Type B
Based on record review, the licensee did not comply with the section cited above. Facility emergency disaster plan was not reviewed/updated. This poses a potential health, safety or personal rights risk to persons in care.
87465(d)(1)Type B
Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of physician contact made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.
87465(d)(2)Type B
Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of contacts made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.
87609(b)(4)Type B
Based on interview and observation, the licensee did not comply with the section cited above. R1 is receiving home health services in the facility. No agreement between licensee and home health agency observed on file. This pose a potential health, safety or personal rights risk to persons in care.
87468.2(a)(4)Type A
(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on medical records, photos, and interviews, licensee did not comply with the section cited. Staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries and bruising while in care, which posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 27, 2024 inspection of EMBRACING SENIORS?

This was a other inspection of EMBRACING SENIORS on March 27, 2024. 4 citations were issued: 2 Type A (serious) and 2 Type B.

Were any citations issued to EMBRACING SENIORS on March 27, 2024?

Yes, 4 citations were issued (2 Type A, 2 Type B). The first citation was for: "(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... wit..."

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·March 27, 2024