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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850202
Report Date: 05/24/2024
Date Signed: 05/24/2024 02:16:56 PM

Document Has Been Signed on 05/24/2024 02:16 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/
DIRECTOR:		BARSALOU, AARONFACILITY TYPE:
772
ADDRESS:22450 COLLINS STTELEPHONE:
(832) 312-9611
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
05/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Robert YoungTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced for a Continuation of the Annual visit, which was started on 03/05/2024. The LPA met with house lead Will Leitzinger. Director of Operations Hayle Jimenez was contacted and arrived at the facility shortly after. LPA explained the reason for the visit. Compliance Director Robert Young was also contacted and arrived at 12:35PM.

Beginning at 12:12PM, the LPA, along with Director of Operations and house lead briefly toured the physical plant to ensure there were no health and safety hazards. A comprehensive physical plant tour was conducted during the initial annual visit. The following was observed:

The facility license and other required postings were observed in the facility's entry way and common areas. Water temperature was checked in all client restrooms and after a slight adjustment, measured within the required range. Restrooms were observed to be relatively clean and sanitary and operational.

Staff Files: During today's visit, 5 (five) staff files were reviewed for documents including but not limited to: CPR and first aid training, annual training records, and fingerprint background clearance. All 5 (five) of 5 (five) staff files reviewed were in compliance with regulation at this time.

Client Files: During today's visit, 5 (five) client files were reviewed for documents including but not limited to: medical assessment, proof of TB test, Admission Agreement, and personal rights. 1 (one) of 5 (five) client files reviewed (Client #1 - C1) did not contain proof of a TB clearance. All remaining files reviewed were complete and contained all required documents.

Medication Review: Beginning at 01:29PM, medications for 2 (two) clients were reviewed. Both 2 (two) of 2 (two) clients medications reviewed were documented and stored in compliance with regulation at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). 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: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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Document Has Been Signed on 05/24/2024 02:16 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/24/2024 at 01:47 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, as 1 (one) of 5 (five) client files reviewed did not contain proof of a TB test, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Compliance Director agreed to ensure Client #1 obtains a TB test and will provide proof of negative TB test results to CCL by POC due date.
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: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
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