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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850202
Report Date: 03/05/2024
Date Signed: 03/05/2024 06:07:23 PM

Document Has Been Signed on 03/05/2024 06:07 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: 5DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Robert YoungTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Kelly Dulek and Valeria Conway arrived at the facility unannounced for a required one year visit. The LPA met with Director of Operations Hayle Jimenez and explained the reason for the visit she asked to wait for Compliance Director Robert Young to start the annual. Compliance Director Robert Young arrived at 10:23 a.m. At 10:43 a.m. the LPA toured the physical plant to ensure there were no health and safety hazards.

KITCHEN: Knives were kept inaccessible to clients in care locked in the Operation's office along with medicine. Appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food with proper expiration dates. Kitchen appliances were in operable condition and looked clean/in good repair. The kitchen was clean and sanitary, with covered trash cans. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. At 03:20 p.m., water temperature was measured in the kitchen sink and measured at 76.8 degrees Fahrenheit (F).

BEDROOMS: All six (6) 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. LPA noted that in male bedroom #2 there were three (3) beds for clients.

RESTROOMS: Some restrooms were clean and sanitary with grab bars and non-skid surfaces. At 10:50 a.m., water temperature in client bathroom #3 on the 2nd floor measured at 93.5 degrees F. At 11:02 a.m. in client restroom on the 2nd floor measured at 98.0 degrees F. At 11:15 a.m. in client restroom #1 on the 1st floor measured 88.0 degrees F. Client shower door #3 on the 2nd floor had hard water stains and shower floors had grime build up and mold/mildew in the grout. Restrooms were stocked with appropriate hygiene and paper products.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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 10
Document Has Been Signed on 03/05/2024 06:07 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/05/2024 at 05:23 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as 4 staff have been employed in the facility since the following dates S1 - 03/04/2024, S2 - 03/01/2024, S3 - 02/03/2024, and S4 - 02/25/2024 and do not currently have criminal record clearance which poses an immediate health and safety rights risk to persons in care.
POC Due Date: 03/06/2024
Plan of Correction
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Management staff were informed that S1, S2, S3 and S4 cannot work or be present in the facility until criminal record clearance is obtained for these individuals.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2024 06:07 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/05/2024 at 05:23 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81009(a)
Posting of License
(a) The license shall be posted in a prominent, publicly accessible location 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 license was not posted in the facility common areas which poses a potential personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Management agreed to post the facility license in the common area and provide proof to CCL by POC due date.
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 restroom #3 was observed with urine staining around the toilet, hard water stains, dirty grout, and mold/mildew around the shower door, bathroom #1 was observed with dirty floor and baseboards and outdoor drain cover was observed to be broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Director of Compliance agreed to ensure all areas of the facility are clean and sanitary. Photos of the above mentioned areas will be sent to CCL by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/05/2024 06:07 PM - It Cannot Be Edited


Created By: Kelly Dulek On 03/05/2024 at 05:23 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: 03/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(e)(1)
Buildings and Grounds
(1) No more than two clients shall sleep in a bedroom unless the program justifies a group living arrangement of more than two persons to a room and such arrangement is approved in writing by the licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as 3 beds were observed in upstairs bedroom #3 and management confirmed verbally that 3 clients have shared that room, which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Management agreed to move the 3rd bed out of the room and to ensure that no more than 2 clients share a room. Proof of 2 beds in Room #3 will be sent to CCL by POC due date.
Type B
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 in all 3 client restrooms and the facility kitchen were observed with water temperatures of 88.0 degrees, 93.5 degrees, 98.0 degrees and 76.8 degrees Fahrenheit which poses a potential health and safety risk to persons in care.
POC Due Date: 03/19/2024
Plan of Correction
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Water temperature was adjusted during today's visit, however had not maintained proper temperatures prior to the end of the visit. A 7-day water temperature log with temperatures recorded at various times of the day in all client restrooms showing water temperatures within the required range will be sent to CCL by POC due date.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024


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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: 03/05/2024
NARRATIVE
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COMMON SPACES: Smoke and common monoxide detectors were tested at 11:56 a.m. and were operable at that time. Client Medications are stored in the staff office downstairs. Fire extinguishers were fully charged and serviced 06/16/2023. During today’s visit, LPAs noted that the room labeled medication/counseling was under construction. Door to the room remained unlocked throughout the visit. LPAs advised Management to secure the door and construction equipment inside. LPA observed a locked laundry room. Facility license was not posted at the time of the visit.

BACKYARD: The backyard had furniture and a covered area for client use. There is an in-ground pool which was locked and appropriately fenced at the time of the visit. The side gate was self-latching however in case of an emergency everyone will use side door with automatic push button.

GARAGE: LPA observed the attached garage, which was locked and contained extra food, emergency water, and storage.

RECORD REVIEW: LPAs reviewed staff records for documents including, but not limited to the following: criminal record clearance, health screening, TB test. Training records were not reviewed during today’s visit. 4 staff files did not contain criminal record clearance for Staff #1, who was hired on 03/04/2024, Staff #2 who was hired on 03/01/2024, Staff #3 who was hired on 02/03/2024, and Staff #4 who was hired on 02/25/2024.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, the LPAs reviewed the facility's infection control plan and Emergency Disaster plan. LPAs noted that the facility is utilizing an old form in place of the current 610D and the form was noted to be incomplete nor had it been updated annually. The facility's infection control plan did not designate an infection control lead, and therefore was incomplete.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued in the amount of $1700.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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