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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221487
Report Date: 06/22/2023
Date Signed: 06/22/2023 05:30:07 PM

Document Has Been Signed on 06/22/2023 05:30 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FENIQUITO RESIDENTIAL CAREFACILITY NUMBER:
191221487
ADMINISTRATOR:YVETTE FENIQUITOFACILITY TYPE:
735
ADDRESS:12933 WELBY WAYTELEPHONE:
(818) 220-8248
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 4CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Yvette Feniquito, AdministratorTIME COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the facility by Baby "Joe " Valencia, Staff. The Administrator was contacted by staff and she arrived at 9:19am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey home consisting of a living room, dining room, a kitchen, 4 resident bedrooms, a staff bedroom, 2 full bathrooms and a detached garage. The facility was fire cleared to serve 6 ambulatory clients. Bedroom #1 - #3 approved for client use. A decrease in capacity from 6 to 4 clients was approved on 2/15/2019. The bedroom previously designated for staff use, now identified as bedroom #4 was reassigned for client use. No evidence that a new fire clearance was requested for the room. The facility is vendorized by the North Los Angeles Regional Center and is a Level 2 home.

On today's visit the following were observed:
  • the living room has a 3 person sofa and a chair
  • the dining room has a table and 4 chairs
  • The kitchen is equipped with a refrigerator and stove.
  • Also located in the kitchen are the washing machine and dryer


continued on LIC809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487
VISIT DATE: 06/22/2023
NARRATIVE
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  • Disinfectants and cleaning solutions are stored in a locked kitchen cabinet
  • knives and hygiene products are locked in a kitchen cabinet.
  • medications are centrally stored in a locked kitchen cabinet
  • Perishable and non-perishable foods met Title 22 requirements
  • The resident rooms contained the required furniture.
  • Bedroom #4 was observed with a metal shelf that served as a closet instead of a portable closet
  • One of the lights in bedroom #4 was inoperable
  • Extra linens were observed in the linen closet and residents' closet
  • the only carbon monoxide detector is located in the living room
  • smoke detectors located in all the 4 client bedrooms and in the hallway were tested and were operational
  • The facility uses cameras in the dining room, living room, kitchen, backyard(alley), by the garage and the center patio.
  • Water tested in the common bathroom read 117.5 degrees Fahrenheit at 3:13pm
  • The only fire extinguisher located in the kitchen was last inspected on 5/1/22 *****
  • The backyard, center patio and front yard were observed to be clean. The center patio was observed with a table, four chairs and had 2 umbrellas for shade.
  • trash cans were tightly sealed
  • Per file review, Marietta Feniquito does not have evidence of current first aid training
  • Administrator Certificate for Yvette Feniquito expires 5/10/2024
  • Physicians orders were not observed in any of the clients files

continued on LIC809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/22/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 06/22/2023 at 03:40 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed, Marietta Feniquito, Licensee does not evidence of current first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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2
3
4
Licensee will submit a signed written plan to LPA, advising as to how the Licensee will come back into compliance with first aid training prior to working alone with the residents by 6/29/23
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487
VISIT DATE: 06/22/2023
NARRATIVE
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  • Per information received on today's visit alterations were made in the bedroom previously identified as the family/staff bedroom. A wall was added to the large bedroom to create a fifth bedroom. Per the administrator, no permits were needed to make the modification. However, due to the addition of the wall, the fire clearance may be impacted.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1 and Chapter 6.

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was given.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/22/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 06/22/2023 at 04:19 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(3)
Fixtures, Furniture, Equipment and Supplies :c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.
(3) Portable or permanent closets and drawer space in each bedroom to accommodate the client's clothing and personal belongings.


This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation the licensee did not comply with the section cited above in 1 4 rooms toured, bedroom #4 was observed with a clothes rack with shelving instead of a portable closet.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee will ensure that bedrooms with no built in closet are provided with portable closets for client use.
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 4 bedrooms toured, one of the 2 overhead light fixtures in Bedroom #4 was not working, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee will ensure that all light fixtures in the facility are operational. Licensee wiill have the light fixture repaired/replaced by 6/29/23
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/22/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 06/22/2023 at 04:31 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers inspected. The fire extinguisher was last inspected on 5/1/22. and this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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Licensee will contact a fire protection company to have the fire extinguisher inspected and serviced or provide a written plan as to how it will ensure that the fire extinguishers will be properly maintained by 6/29/23
Type B
Section Cited
CCR
80075(D)
80075 Health Related Services
(D) 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 client'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 is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 files reviewed, 2 of the client files do not have physiciians order for the medications being taken by the the 2 resdients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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The Licensee will contact the physician or the residents' pharmacy to obtain a copy of the physicians order for each of the clients and maintain in the clients file by POC date.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/22/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 06/22/2023 at 04:49 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FENIQUITO RESIDENTIAL CARE
FACILITY NUMBER: 191221487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in 1 out of 4 rooms toured. Licensee added a wall to the former staff room to create a fifth bedroom without informing Licensing or verifying the impact of the addition to the facility's fire clearance, which posed/poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2023
Plan of Correction
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2
3
4
The Licensee will contact the city to obtain a written confirmation that permits are not required for the addition of the wall in bedroom #4 and to determine if a new fire clearance will be needed
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023


LIC809 (FAS) - (06/04)
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