195850156-7-14-2023-29-AS-BBAI-CTQU3S-20230714151402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850156
Report Date: 07/14/2023
Date Signed: 07/14/2023 03:14:13 PM

Document Has Been Signed on 07/14/2023 03:14 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:	CNS QUAKERTOWN		FACILITY NUMBER:	195850156
ADMINISTRATOR:	MARC SAINT CLAIR		FACILITY TYPE:	735
ADDRESS:	5135 QUAKERTOWN AVENUE		TELEPHONE:	(661) 872-3408
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY: 6		CENSUS: 4	DATE:	07/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Marc J Saint Clair - Administrator		TIME COMPLETED:	03:30 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 Analysts (LPAs) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 12:50pm. Upon arrival LPA met with Administrator Marc J Saint Clair and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. All (4) clients and staff were currently off site. DINING ROOM / KITCHEN: The LPAs began the inspection in the kitchen/food service area at 9am. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean. COMMON AREAS: LPAs inspected the common areas throughout the all common areas have been appropriately furnished. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced December 2022. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common spaces.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CNS QUAKERTOWN	FACILITY NUMBER: 195850156
	VISIT DATE: 07/14/2023

NARRATIVE

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BEDROOMS: At approximately 1:20pm, LPAs inspected bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. Cleaning supplies and chemicals are stored and inaccessible to residents. There is a shaded patio area with patio furniture including a table and chairs for resident use. The LPA did not observe any obstructions to emergency exit pathways. There is a detached unit used for an office space and meeting area at this time. LPA did not observe any poisonous or dangerous plants in the garden at this time. No large bodies of water accessible to residents at the time of visit.

RECORDS: Records review began at 02:00pm, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.

(4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

MEDICATIONS: Medications review began at approximately 02:30pm The medications are centrally stored in a cabinet area next to the family room. All cabinets storing medications and medical supplies were observed inaccessible to clients at this time. Medications are properly documented on the centrally stored medications and destruction record.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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: CNS QUAKERTOWN	FACILITY NUMBER: 195850156
	VISIT DATE: 07/14/2023

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Continued from 809-C

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. The facility has 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 each private bedroom as an isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

There were no clients are staff to interview during the time of the visit.

LPA obtained the following documents - Census, Staff schedule, and updated Limited Liability insurance.

Exit interview conducted and copy were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC809 (FAS) - (06/04)

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