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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600690
Report Date: 05/30/2024
Date Signed: 05/31/2024 07:48:20 AM

Document Has Been Signed on 05/31/2024 07:48 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:THERAPEUTIC LIVING CENTERS FOR THE BLINDFACILITY NUMBER:
197600690
ADMINISTRATOR/
DIRECTOR:		HITZ, JADEFACILITY TYPE:
735
ADDRESS:17712 PARTHENIATELEPHONE:
(818) 349-3440
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 3DATE:
05/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Caretha Mitchelle- House Manager TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff, Tina Harris and explained the reason for the visit. Administrator, Joshua Cration could not attend the annual for the day due to an emergency. At approximately 1:10 PM, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the hallway between Clients rooms. The fire extinguisher is located in the kitchen and laundry room. The charge date is May 17,2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. Bedrooms: There were three (3) bedrooms designated for clients' use. All three(3) bedrooms, in use by clients, were properly furnished with appropriate beddings and linens with sufficient lighting.
Bathrooms: There are three (3) bathrooms designated for clients' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 110.6 and 113.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished.Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry room is accessible through one of the activity areas leading to the garage which is locked an inaccessible to the clients. There is one washer and dryer in the laundry area. The toxins are kept in the garage in a cabinet and locked.
Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.
Medications: Medication and Medication Records were review for proper documentation.
Temperature: Facility maintains a comfortable temperature of 70 degrees Fahrenheit
Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. LPA observed that Staff (S1) has missing forms in their file, Staff (S2) and Staff (S3) have no physical file at the facility. Staff couldn't explain the reason for the missing folders.
(Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690
VISIT DATE: 05/30/2024
NARRATIVE
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Cash Resources: At 3:00 PM, LPA with the assistance of the caregiver reviewed cash resources for three clients. Logs and cash resources weren't consistent. S1 stated that they aren't responsible for any of the cash sources neither the logs. LPA was unable to conducted cash records review.

Exit interview conducted, Citations issued, Appeal Rights given and copy of this report delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/31/2024 07:48 AM - It Cannot Be Edited


Created By: Mariana Agban On 05/30/2024 at 04:11 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)


This requirement is not met as evidenced by: 87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1 is missing forms LIC 501 and LIC 508. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administrator will submit complete staff forms to the LPA by the POC date
Type B
Section Cited
CCR
80026(h)


This requirement is not met as evidenced by: 80026(h)Safeguards for Cash Resources, Personal Property and Valuables. Each licensee shall maintain accurate records of accounts of client cash resources, personal property valuables entrusted to his/her care

Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. The facility failed to maintain accurate financial ledgers and other documents to keep total and correct accounting of the clients P&I records. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administrator will submit accurate records of three (3) clients cash resources by the POC 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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/31/2024 07:48 AM - It Cannot Be Edited


Created By: Mariana Agban On 05/30/2024 at 04:28 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)


This requirement is not met as evidenced by: 87412(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited. Staff couldn't provide LIC 500 to LPA. S2 and S3 have no physcial file in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Administraator will email LIC 500, S2 and S3 employee file to the LPA by the POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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