195850202-3-21-2025-29-AS-QHUH-DEYU3F-20250321151327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850202
Report Date: 03/21/2025
Date Signed: 03/21/2025 03:19:27 PM

Document Has Been Signed on 03/21/2025 03:19 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:	PSYCLARITY HEALTH INC.		FACILITY NUMBER:	195850202
ADMINISTRATOR/ DIRECTOR:	BARSALOU, AARON		FACILITY TYPE:	772
ADDRESS:	22450 COLLINS ST		TELEPHONE:	(832) 312-9611
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 6	DATE:	03/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Robert Young - Compliance Director		TIME VISIT/ INSPECTION 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 (LPA) Quoc Huynh and Angela Barutyan arrived at the facility unannounced for a required one year visit. The LPAs met with Clinical Supervisor Shalmar Neal at 9:53AM and explained the reason for the visit. LPAs met with Director of Operations Hayle Jimenez who arrived at 10:19AM and Compliance Director Robert Young who arrived at 10:58AM. Entrance interview conducted. Beginning at 10:08AM LPAs, along with Clinical Supervisor and Director of Operations, toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The facility is a two story building, the following was observed: KITCHEN/GARAGE: The LPAs toured the facility kitchen at 10:15AM. Knives are stored inaccessible in the Operation’s office along with medication. Cleaning supplies are stored inaccessible and away from all food preparation areas. Kitchen appliances were in operable condition. Management indicated lunch and dinners are catered from a third party company and clients can prepare their own meals with staff supervision. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water are stored in a locked closet and regularly updated as needed. LPAs observed the attached garage, which was locked and contained extra food, emergency water, and storage. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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 03/21/2025 03:19 PM - It Cannot Be Edited

Created By: Quoc Huynh On 03/21/2025 at 02:27 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: 03/21/2025

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as 1 out of 6 bathrooms had mold/mildew build up and a non-draining sink which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	Compliance Director agreed to sanitize toilet and repair the sink's drainage system in client bedroom #4's private bathroom and submit proof to CCL by 04/04/2025.

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:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Quoc Huynh

LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PSYCLARITY HEALTH INC.	FACILITY NUMBER: 195850202
	VISIT DATE: 03/21/2025

NARRATIVE

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BEDROOMS: There are four (4) client rooms: two (2) shared, two (2) private; and two (2) rooms utilized for office space. All 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: There are six (6) total bathrooms in the facility; one (1) office bathroom, four (4) private client bathrooms, and one (1) shared common bathroom. Some restrooms were clean and sanitary. At 10:10AM, client restroom in bedroom #4 was observed to have urine and mold/mildew build up around the base of the toilet. At 10:11AM, water temperature in bedroom #4 was measured at 113.7 degrees F and LPAs observed the sink was not draining properly. Between 10:12AM-10:26AM, client restrooms measured between 102.9 degrees F to 116.2 degrees F, which was not within the required range of 105-120 degrees F. A conversation was had with the Director of Operations who indicated the water heater was not consistent throughout the building. Restrooms were stocked with appropriate hygiene, paper products, and hand washing signs.

COMMON SPACES: Smoke and carbon monoxide detectors were tested at 10:59AM and were operable at that time. Client Medications are stored in the staff office downstairs. Fire extinguishers were fully charged and serviced 06/03/2024. LPAs observed a locked laundry room. Living room and group room furniture was observed to be in good condition.

BACKYARD: The backyard had furniture and a covered patio 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.
Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PSYCLARITY HEALTH INC.	FACILITY NUMBER: 195850202
	VISIT DATE: 03/21/2025

NARRATIVE

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MEDICATION REVIEW: Beginning at 10:29AM, medications for two (2) clients were reviewed. Both two (2) of two (2) clients medications reviewed were documented and stored in compliance with regulation at this time.

RECORD REVIEW: At 11:05AM, LPAs reviewed staff records for documents including, but not limited to the following: criminal record clearance, CPR and first aid training, health screening, TB test. All five (5) of five (5) staff files reviewed were in compliance with regulation at this time. LPAs reviewed five (5) client files for documents including but not limited to: medical assessment, proof of TB test, Admission Agreement, and personal rights. All files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: LPAs reviewed the facility's infection control plan and Emergency Disaster plan. LPAs noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with the last drill conducted on 02/26/2025.

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: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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