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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600865
Report Date: 05/18/2024
Date Signed: 05/18/2024 12:12:26 PM

Document Has Been Signed on 05/18/2024 12:12 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
Lookup Error,
, CA
FACILITY NAME:VAGTHOL'S RESIDENTIAL CARE CENTERFACILITY NUMBER:
197600865
ADMINISTRATOR/
DIRECTOR:		CHAMU-NESTOR, FRANCISCAFACILITY TYPE:
735
ADDRESS:418 N. MARIPOSATELEPHONE:
(818) 562-1447
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 6DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Rodel Serrano - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Sheila May Gelvezon, Direct Care Staff and Rosemarie Lopez Direct Support Professional I & II (DSP I & II) and explained the purpose of the visit. Administrator, Rodel Serrano was called on the phone and arrived at 10:09am to assist LPA with the inspection. The facility is licensed to care for (6) Developmentally Disabled Adults, non ambulatory, ages 18 through 59. All clients residing at this Specialized facility receive case management services provided by Frank D. Lanterman Regional Center. The facility is a level 4I. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The staff stated that they use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood, contains a total of (5) client bedrooms,(2) bathrooms, staff lounge, a living room, kitchen, dining area, backyard with shaded area, and detached garage. Currently, there are six (6) clients living in the facility. (5) of the clients are over the age of 59 and only (3) clients have exceptions granted by CCL. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. LPA observed (4) clients are using half-length bedrails, of which (3) have physician's orders. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towel and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and has a shaded area and sitting area. There is a separate shed that is locked where incontinent supplies and old clothes are stored. Laundry area is in the detached garage. There are (3) fire extinguishers which were serviced on 09/25/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Readings were 110.8 deg F in bathroom #1 and 110.3 deg. F in bathroom #2.
Operational Requirements: A current Plan of Operation was not reviewed, but a copy will be emailed to LPA. Administrator stated that the Infection Control Plan has been added to the Plan. Surety Bond in the amount of $10,000 is in effect and will expire on 12/01/2024. Last Fire Drill was conducted on 05/16/2024 and earthquake drill was conducted on 04/11/2024. *****REPORT CONTINUED ON LIC809-C*****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197600865
VISIT DATE: 05/18/2024
NARRATIVE
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Staffing: A total of sixteen (16) staff members including the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 12/04/2024. Administrator does not have a valid HIV/AIDS training.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility provides internet services to all clients and have access to the facility phone. Administrator stated that none of the clients have a cell phone but all (6) have their own IPads. LPA interviewed only (1) client as the other (5) clients are non verbal.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. One (1) client is on a PKU diet, (1) client has food allergy, (2) clients foods are pureed and chopped.
Client Records-Incident Reports: LPA reviewed Client files for C1 through C4. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.
Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C6 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.
Incidental Medical Services: None of the clients at this home has a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited, exit interview, appeals rights and a copy of this report was provided to the Administrator, Rodel Serrano.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/18/2024 12:12 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/18/2024 at 11:37 AM
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
,
, CA

FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197600865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the Administrator did not comply with the section cited above in which the Administrator did not have HIV/AIDS training as required which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will take the required HIV/AIDS training classes and send proof of completion to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that Client #6 (C6) was observed to be using manual restraint (seat belt) but no physician's order or exception granted by CCL which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will submit an order from C6's physician allowing use of seatbelt as a restraint and send exception request to CCL Woodland Hills 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/18/2024 12:12 PM - It Cannot Be Edited


Created By: Bennette Pena On 05/18/2024 at 11:37 AM
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
,
, CA

FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197600865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the Administrator did not comply with the section cited above in that Client #4/C4 uses a half-length bedrail but no physician's order on file which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator to send physician’s order authorizing use of half-length bedrail for C4 to CCL/LPA by POC due date.
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator did not comply with the section cited above in which (2) (C1 & C3) out of (5) clients in care are over the age of 59 and no exception granted by CCL which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 05/24/2024
Plan of Correction
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Administrator will send an exception request letter for the (2) clients (C1 & C3) over the age of 59 who are currently residing in the facility. Request letter along with required documentation to be sent to CCL/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
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