195850143-4-5-2022-29-AS-SWAR-CD7QDE-20220405120436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850143
Report Date: 04/05/2022
Date Signed: 04/05/2022 12:05:27 PM

Document Has Been Signed on 04/05/2022 12:05 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A COMPASSION VALLEY		FACILITY NUMBER:	195850143
ADMINISTRATOR:	KUYUMCHYAN, BREANNA		FACILITY TYPE:	740
ADDRESS:	7460 MAMMOTH AVE.		TELEPHONE:	(818) 983-9165
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 4	DATE:	04/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eva Elizalde		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff upon arrival, and explained the reason for the visit.

At 9:25 a.m., the LPA conducted a record review that confirmed Staff #1 (S1) is not associated to the facility. Staff #2 (S2) confirmed that S1 has been working at the facility for two (2) days without association to the facility. The LPA advised S2 that all staff are to obtain a California clearance or a criminal record exemption as required by the Department prior to working at a licensed facility. On 7/29/2021, the Department issued a citation and assessed civil penalties under section 87355(e)(1) for staff non-association. Therefore, the facility is being issued a repeat violation, and civil penalties are being assessed for S1 not having a criminal record clearance prior to working at the facility. S2 acknowledged and stated they will be covering for the rest of the day, until another staff that is associated is able to relieve.

The LPA toured the physical plant areas inside and outside, with S2 at 9:32 a.m., to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. At 9:27 a.m., the LPA observed two (2) boxes of cigarettes in room #2. Staff immediately stored the cigarettes in a secured closet. On 7/30/2021, the Department issued a citation for section 87705(f)(2). Therefore, civil penalties are being assessed today for a repeat violation, as the licensee failed to ensure the cigarettes were stored inaccessible to residents with dementia.

Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY	FACILITY NUMBER: 195850143
	VISIT DATE: 04/05/2022

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RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, and paper products in each restroom. The LPA advised staff to ensure that all bathrooms have hand-washing signs. Between 9:37 a.m. and 9:41 a.m., hot water temperatures measured between 113.5 and 113.8 degrees Fahrenheit in the common and private bathroom(s).

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 118.7 degrees Fahrenheit at 9:41 a.m.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. One (1) fire extinguisher was observed to be fully charged.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is attached to the facility. The garage contains additional nonperishable and perishable food items, and is being utilized as additional storage for supplies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.), and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil Penalties assessed for repeat violations. Failure to correct the deficiencies may result in additional civil penalties.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2022 12:05 PM - It Cannot Be Edited

Created By: Salia Walker On 04/05/2022 at 11:26 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY	FACILITY NUMBER: 195850143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 as S1 is not associated to the facility and does not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/06/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed not to allow S1 to return to the facility until criminal record clearance is obtained from DOJ. The lIcensee has agreed to submit proper documentation to CCLD, once S1 is cleared, to associate S1 to the facility.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as there were two (2) boxes of cigarettes in room #2 accessible to residents with Demtia, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2022
	Plan of Correction
1 2 3 4	Staff stored the cigarettes in a secured closet at the time of observation. POC met.

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:

Salia Walker

LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC809 (FAS) - (06/04)

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