195850156-7-22-2024-29-AS-VCOY-D7EU9F-20240722152304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850156
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:23:13 PM

Document Has Been Signed on 07/22/2024 03:23 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CNS QUAKERTOWN		FACILITY NUMBER:	195850156
ADMINISTRATOR/ DIRECTOR:	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: 5	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Marc Saint Clair		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:00 A.M. No one was home when LPA arrived. LPA contacted, Program Director Marc Saint Clare, via phone. Program Director stated that he will be arriving soon. At 11:00 A.M., upon arrival of Program Director, LPA explained the reason for the visit. 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 five (5) clients and staff were currently off site. KITCHEN: The LPA began the inspection in the kitchen/food service area at 11:32 A.M. Knives are kept locked and inaccessible to clients in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. At 11:35 A.M. hot water was measured at 116.8 degrees Fahrenheit. COMMON AREAS: The LPA inspected the common areas throughout all common areas have been appropriately furnished. LPA observed cameras in commons spaces, Program Director stated they record with out audio. The common areas were observed to be properly furnished and relatively clean at the of the visit. The facility maintained a comfortable temperature of 76 degrees Fahrenheit. At 11:29 A.M. smoke detector(s) and carbon monoxide detectors were tested and operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced on December 2023. All exits have functioning auditory devices and were operational at the time of the visit. Continued on LIC 809

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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 4

Document Has Been Signed on 07/22/2024 03:23 PM - It Cannot Be Edited

Created By: Valeria Conway On 07/22/2024 at 02:45 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: CNS QUAKERTOWN	FACILITY NUMBER: 195850156
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80019(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, and interviews, licensee did not comply with the above section by not ensuring 5 out of 5 (S1, S2, S3, S4, S5) had fingerprint association transferred to the facility prior working, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 07/24/2024
	Plan of Correction
1 2 3 4	Program Director agreed to make sure all staff are associated to the facility and to update LIC 500 if necessary. Also, submit proof of both requirements by 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.

SUPERVISOR'S NAME:

Desaree Perera

LICENSING EVALUATOR NAME:

Valeria Conway

LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CNS QUAKERTOWN	FACILITY NUMBER: 195850156
	VISIT DATE: 07/22/2024

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
26
27
28
29
30
31
32

Continued from LIC 809

BEDROOMS: Between 11:16 A.M. - 11:30 A.M, LPA inspected all 6 bedrooms. The client's 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. One bedroom is vacant at the time of the visir.

BATHROOMS: Between 11:14 A.M. and 11:30 A.M., LPA inspected all 5 bathrooms. Hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Client's 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.

LAUNDRY ROOM: The facility has a laundry room where the washer and dryer are held. Laundry and cleaning supplies were observed to be inside a locked cabinet in the laundry room.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. Cleaning supplies and chemicals are stored and inaccessible to clients. Emergency food and water is stored in the garage. There is a shaded patio area with patio furniture including a table and chairs for clientuse. 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. No large bodies of water accessible to clientat the time of visit.

RECORDS: Records review began at 12:30 P.M., five (5) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.Additionally, LPA reviewed five (5) personnel records including Program Director. All files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Information gathered during the course of the annual visit reflected that Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) are all fingerprint cleared but not associated to the facility. Moreover, a review of the Guardian System reflected that Staff #5 (S5) has been employed at the facility since 06/06/2011 however, was associated at today, 07/22/2024 at 12:32 P.M.
Continued on LIC LIC 809

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: CNS QUAKERTOWN	FACILITY NUMBER: 195850156
	VISIT DATE: 07/22/2024

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
26
27
28
29
30
31
32

Continued from LIC 809-C

MEDICATIONS: Medications review began at approximately 2:15 P.M., medication for all clients are centrally stored in a cabinet area next to the family room. All cabinets storing medications are in individualized drawers locked and inaccessible to clients at this time. LPA observed four (4) complete First Aid Kit through the facility.

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.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited
(Refer to LIC 9099-D). Exit Interview Conducted. Failure to correct the deficiencies may result in civil
penalties. A Civil Penalty in the amount of $2,500 was assessed during today's visit. Appeal Rights Discussed.

A hard copy of this report Issued to Program Director.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4