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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202138
Report Date: 05/20/2022
Date Signed: 05/20/2022 10:27:16 AM

Document Has Been Signed on 05/20/2022 10:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TIERRA DEL SOLFACILITY NUMBER:
191202138
ADMINISTRATOR:NANCY BISSONETTE-ANDREWFACILITY TYPE:
775
ADDRESS:9919 SUNLAND BOULEVARDTELEPHONE:
(818) 352-1419
CITY:SUNLANDSTATE: CAZIP CODE:
91040
CAPACITY: 304CENSUS: 18DATE:
05/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Teresa Rathsam - Senior Regional DirectorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Gary Tan and Deputy Director (DD) Kevin Gaines conducted an unannounced case management visit to this facility to this facility to issue a deficiency observed during physical plant tour today with Program Director Sandy Lara.

During the physical plant tour at 8:47 AM at the common dining area, LPA observed that there is a disinfectant spray by the kitchen sink accessible to clients. Clients were observed at the dining table waiting for their program to start.

Citation issued. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2022 10:27 AM - It Cannot Be Edited


Created By: Jose Gary Tan On 05/20/2022 at 09:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIERRA DEL SOL
FACILITY NUMBER: 191202138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
CCR
82087(a)(3)

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Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored
where inaccessible to clients.

This requirement is not met as evidenced by:
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Program Director immediately kept and locked the disinfectant. Senior Regional Director agreed to remind all staff to always keep any toxic materials lock and will send proof of attendance to CCL.
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Based on LPA observation the licensee did not ensure that all toxic cleaning agents are inacessible to residents. This poses an immediate health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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