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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850202
Report Date: 02/01/2023
Date Signed: 02/01/2023 03:44:38 PM

Document Has Been Signed on 02/01/2023 03:44 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PSYCLARITY HEALTH INC.FACILITY NUMBER:
195850202
ADMINISTRATOR:BARSALOU, AARONFACILITY TYPE:
772
ADDRESS:22450 COLLINS STTELEPHONE:
(832) 312-9611
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 3DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Hailey JimenezTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required one year visit. The LPA met with Director of Operations Hayle Jimenez and Compliance Director Robert Young and explained the reason for the visit. The LPA toured the physical plant to ensure there were no health and safety hazards.

KITCHEN: Knives were kept inaccessible to clients in care. At 12:23 p.m. the LPA observed an unlocked kitchen drawer containing powder dish soap pods accessible to clients in care. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. At 12:25 p.m. the LPA observed two (2) packs of tomatoes that were growing mold. BEDROOMS: Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:15 p.m., water temperature in client bathroom #2 on the 1st floor measured at 121.8 F. At 12:30 p.m. in visitor/staff/client restroom on the 1st floor measured at 157.1 F. At 12:38 p.m. in client restroom #1 on the 1st floor measured 124.3 F. At 12:43 p.m. temperature in the therapist office restroom on the 2nd floor measured 146.3 F. At 12:47 p.m.in client restroom #3 on the 2nd floor measured 156.2 F. Client shower door #3 on the 2nd floor had hard water stains and shower floors had grime build up in the grout. Restrooms were fully stocked. Hand-washing signs were observed in restrooms. COMMON SPACES: Smoke and common monoxide detectors were tested at 12:10 p.m. and were operable at that time. At 12:13 p.m. the LPA observed the smoke detector in client bedroom #1 was missing and not attached. The smoke detector had been removed due to beeping. Medications are stored in the staff office downstairs, at 12:01 p.m. the LPA observed the medication cabinet to be unlocked. Fire extinguishers were fully charged and serviced 6/13/2022. The backyard had furniture and a covered area for client use. There was an in-ground pool, but it was locked and appropriately fenced at the time of the visit. The side gate was self-latching.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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: PSYCLARITY HEALTH INC.
FACILITY NUMBER: 195850202
VISIT DATE: 02/01/2023
NARRATIVE
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THERAPY AND STAFF: The LPA observed the Group/Activity Room, and Staff Room on the first floor and the counseling/therapy Room, and staff office on the 2nd floor. The attached garage was locked and inaccessible to clients. The garage contained additional food supplies, house supplies and gardening supplies. All rooms were clean and clear of obstructions.

INFECTION CONTROL: The LPA did not observe a central entry point for screening and temperature checks and reminded the Compliance Director of the department’s recommendations. The LPA was not appropriately screened upon entry into the facility. Staff were not wearing appropriate face coverings. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations. The staff are up to date regarding testing, visitation, and vaccine requirements. The LPA reminded the Compliance Director to ensure staff are reminded of COVID-19 protocols. Personal Protection Equipment (PPE) supply was adequate. The facility's procedures as it pertains to infection control are to be reviewed and maintained as regulation requires.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 02/01/2023 03:44 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/01/2023 at 02:41 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: PSYCLARITY HEALTH INC.
FACILITY NUMBER: 195850202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81087(l)
Buildings and Grounds
(l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions and poisons are stored where inaccessible to clients.

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 as the kitchen drawer next to the sink was observed to have unlocked powder dish detergent pods which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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The Licensee agreed to the following:
1. Lock the dish detergent pods to be inaccesible to clients. Submit proof CCL no later than 2/2/23.
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 as water temperatures throughout the facility measured between 121.8 F and 156.2 F. which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/07/2023
Plan of Correction
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The Licensee agreed to the following:
1. Adjust water heater and adjust hot water temperature to not less than 105 degrees F and not more than 120 degrees F no later than 2/2/23. Plan of correction met at the time of the visit.
2. Submit a 5 day log of water temperatures of all sinks to CCL no later than 2/7/23.
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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 02/01/2023 03:44 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/01/2023 at 02:41 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: PSYCLARITY HEALTH INC.
FACILITY NUMBER: 195850202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(m)
Fixtures, Furniture, Equipment, and Supplies
(m) All social rehabilitation facilities, except facilities with sprinkling systems, shall have an approved, commercially manufactured and battery operated smoke detector installed in the hallway(s) in each sleeping area in the home. The smoke detectors shall be audible in each bedroom or sleeping room.

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 as the smoke detector in bedroom #1 downstairs was not in place which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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The Licensee agreed to the following:
1. Install a functioning smoke detector in downstairs bedroom #1. Submit proof to CCL no later than 2/2/23.
Civil Penalty assesed.
Type A
Section Cited
CCR
81075(o)(2)
81075 Health-Related Services (o) For each client that the licensee determines there is a need, a licensee shall develop an individual medication-management plan provided all of the following conditions are met: (2) The licensee shall ensure that the client's medications are stored so that they are inaccessible to other clients in the facility.

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 as the medication cabinet was observed to be unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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The licensee agreed to the following:
1. Lock the medication cabinet. Plan of correction met at the time of the visit.
2. Review medication protocols with all staff and submit proof to CCL no later than 2/3/23.
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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 02/01/2023 03:44 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/01/2023 at 02:41 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: PSYCLARITY HEALTH INC.
FACILITY NUMBER: 195850202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(a)
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 as upstairs client bathroom was not clean and the shower drain was missing the cove which poses a potential health and safety risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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The Licensee agreed to the following:
1. Clean bathroom shower and replace cap on shower drain. Submit proof no later than 2/3/23.
Type B
Section Cited
CCR
81076(a)(1)
Food Service
(a) In a social rehabilitation facility providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 as 2 packages of tomatoes found in the refrigerator were observed to be moldy which poses a potential health and safety risk to persons in care.
POC Due Date: 02/02/2023
Plan of Correction
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The Licensee agreed to the following:
1. Dispose of the moldy tomatoes. Plan of correction met at the time of the visit.
2. Coduct an audit of all refrigerated items to ensure they are not expired. Submit to CCL no later than 2/2/23.
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:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
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