195850238-4-11-2024-29-AS-VCOY-D48KU8-20240411081216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850238
Report Date: 04/10/2024
Date Signed: 04/11/2024 08:12:38 AM

Document Has Been Signed on 04/11/2024 08:12 AM - 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:	BAGET'S HOME		FACILITY NUMBER:	195850238
ADMINISTRATOR/ DIRECTOR:	BAGET, BADUNG DAVOU		FACILITY TYPE:	735
ADDRESS:	7524 WISH AVE		TELEPHONE:	(818) 518-4635
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 3		CENSUS: 3	DATE:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Badung Baget		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE

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At 9:00 a.m. Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual. Upon arrival LPA met with Administrator Badung Baget and explained the reason for the visit. This facility is a Regional Center Level 3 home.

The facility is a one (1) story home. At 9:15am 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. The facility has four (4) private bedrooms, Room #1 is approved for non-Ambulatory and has a direct exit to the outside. Rooms #2 and #3 are both private and do not have a direct exit to the outside. Room #4 is a designated staff room.

All resident rooms are well furnished with beds, nightstands, lamps, chests of drawers, chairs, and closet space. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

There is one (1) full bathroom in the common area. Inside staff room there is a full bathroom designated for staff only. The resident’s bathroom has a shower with non-skid materials and shower has grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 113*F and 115*F.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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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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: BAGET'S HOME	FACILITY NUMBER: 195850238
	VISIT DATE: 04/10/2024

NARRATIVE

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Continued from LIC 9099-C

Medications, resident, and staff records are stored in the file cabinet, which is currently located in the office. At 12:30 p.m. LPA reviewed three (3) resident’s files. LPA observed signed Admission Agreements, ID and Emergency contact forms. At the time of the visit administrator didn’t have the following forms available Medical Assessments, Physicians Report Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does not handle cash resources for the residents in care. All three (3) clients were admitted in March 2024, administrator is working with Regional Center to get necessary forms completed.

The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They are located in a cabinet above the fridge in the kitchen.

Kitchen knives and sharp objects are stored in a locked box, in a locked cabinet to the left of the kitchen sink. The supply of dishes, utensils, pots, pans and drinkware is adequate. The supply of nonperishable food is adequate. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry, and house cleaning supplies are stored in a locked cabinet located under the sink. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely.

Facility has hard wired smoke alarm system. At 10:40 a.m. LPA tested smoke detector and carbon monoxide detectors they were functioning properly during the time of visit. There are (2) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.

Continued on LIC9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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: BAGET'S HOME	FACILITY NUMBER: 195850238
	VISIT DATE: 04/10/2024

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Continued from LIC9099-C

The laundry area is located in the backyard. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a linen closet by room #2. Extra incontinence supplies are stored in the linen closet as well. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout. The emergency telephone numbers are posted on a bulletin board in living room. Other required postings are posted near the entry and in living room as well.

The exterior passageways were clean and clear of any obstructions. The gate to the driveway on the right side of home is moved manually. There is a gate with a self-latching mechanism for persons to exit the back yard. There are no bodies of water on the premises at the present time. There is no garage on site.

LPA interviewed Administrator during the visit. The follow deficiencies were observed. Exit interview conducted and report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2024 08:12 AM - It Cannot Be Edited

Created By: Valeria Conway On 04/10/2024 at 02:42 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: BAGET'S HOME	FACILITY NUMBER: 195850238
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

80069(b)/(c)(a)

• 80069(b) Client Medical Assessment. In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. • 80069(c)(a) The medical assessment shall include the following: The results of an examination for communicable tuberculosis and other contagious/infectious diseases. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 clients not having medical assessment nor needs and service Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Licensee will provide Physician report and Needs and service plan by POD Due date.

Type B

Section Cited

CCR

85068.2(a)

85068 (a) Prior to admission, the licensee shall determine whether the facility's program can meet the prospective client's service needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 clients not having medical assessment nor needs and service Plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Licensee will provide Physician report and Needs and service plan by POD 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:

Desaree Perera

LICENSING EVALUATOR NAME:

Valeria Conway

LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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