191222779-7-30-2025-31-AS-LNCA-DK3SBM-20250730134411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222779
Report Date: 07/30/2025
Date Signed: 07/30/2025 01:44:24 PM

Document Has Been Signed on 07/30/2025 01:44 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:	DESTAJO'S ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	191222779
ADMINISTRATOR/ DIRECTOR:	THERESE GAJETE		FACILITY TYPE:	735
ADDRESS:	9938 SWINTON AVE		TELEPHONE:	(818) 893-5123
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 5	DATE:	07/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	Therese Gajete- Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Dominga Reynante, and explained the reason for the visit. Approximately, around 9:10 AM administrator, Therese Gajete, arrived and was explained for the reason of the visit. At 9:20 AM, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. At 11:00 AM the smoke alarms were tested and are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the dining room and office. The charge date is 4/28/2025. During the visit the facility is at 75 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet under the sink. The menu was posted for review (ARF), snacks and beverages are available for the resident in the facility when they want. Properly labeled medications were locked in the kitchen cabinets. Bedrooms: There were six (6) bedrooms designated for residents' and staff use. Four (4) of the that are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1 is a shared room. Room #2, room #3, and room #4 are private rooms for clients. There are two (2) staff bedroom in the facility and is located beside the office, staff bedrooms are locked with no medication in sight. Bathrooms: There are two (2) bathrooms designated for residents' and staff use. Bathrooms were properly supplied and had functional fixtures. Continue to LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DESTAJO'S ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 191222779
	VISIT DATE: 07/30/2025

NARRATIVE

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Hot water temperature was measured at 107.3 degrees Fahrenheit for bathroom #1 located in the hallway beside room #2. Bathroom #2 is only used by the staff and is located across the laundry area. Cleaning supplies are in a locked cabinet in the storage room in bathroom #1. Towels and washcloths are not shared. There was enough clean linen available in the cabinets in the hallway. Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Clients dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. Fire place is close, block-off and non-operational. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance. Office space is beside the kitchen.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility has a swimming pool, this is locked and has a fenced around it. There is no garage at the facility, just a car port. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA reviewed client’s files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPA. Planned activities are offered. LPA reviewed five (5) of the five (5) residents funds and observed receipts and funds balanced.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Medications: Medication and Medication Records (MMR) were review for proper documentation. C5 Amlodipine medication was not given in the morning. Evening bubble pack Risperidone and Levetiracetam medication was given in the morning. Deficiencies will be cited in LIC 809-D.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were observed during the visit. Exit interview conducted and a copy of the report issued.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/30/2025 01:44 PM - It Cannot Be Edited

Created By: Leslie Ngo-Castaneda On 07/30/2025 at 01:21 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: DESTAJO'S ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 191222779
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(5)(B)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions. 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 1 C5 Amlodipine medication was not given on the AM. PM bubble pack Risperidone and Levetiracetam medication was given in the AM, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2025
	Plan of Correction
1 2 3 4	Licensee agreed to vendor before training and send certification before POC due date.

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.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025

LIC809 (FAS) - (06/04)

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