<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220171
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:27:36 PM

Document Has Been Signed on 08/19/2024 04:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:THERAPEUTIC LIVING CENTERS FOR THE BLINDFACILITY NUMBER:
191220171
ADMINISTRATOR/
DIRECTOR:		SANDOVAL,JUANFACILITY TYPE:
775
ADDRESS:7955 LINDLEY AVENUETELEPHONE:
(818) 708-4940
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 90CENSUS: 90DATE:
08/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Juan Sandoval, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20230512112037. LPA met with the Administrator, Juan Sandoval. LPA explained the reason for the visit.

During the visit, LPA was informed that on 05/04/2023, C1 arrived at the Day-Program with a bump on his right check and below the check area and upper eyebrow area from one of the group homes. The Administrator contacted the group home supervisor/House Service Coordinator to inform them of the incident. C1 was assessed by the house nurse at the group home by the evening and later taken to the ER for further medical assessment. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. In addition, the Administrator admitted that no incident report was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPA informed the Administrator to submit an incident report that occurred on or before :
  • 05/04/2023 (one incident)
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/19/2024 04:27 PM - It Cannot Be Edited


Created By: Huma Rahimi On 08/19/2024 at 03:42 PM
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: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 191220171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
80061(b)

1
2
3
4
5
6
7
80061(b)Upon the occurrence... of any of the events specified…next working day during its normal business hours. In addition, a written report containing the information…shall be submitted to the licensing agency within seven days...This was not met in evidence by:
1
2
3
4
5
6
7
Administrator shall ensure a written report is submitted to the licensing agency and to the person responsible for the clients within seven (7) days of the occurrence of any of the events. LPA received the incident report. POC cleared during the visit.
8
9
10
11
12
13
14
Based on interviews, observations and documentation review an incident occurred on 05/04/23 and it was not reported in a timely manner, which poses a potential health and safety risk to the clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2