197601547-12-5-2024-31-AS-APAA-DBP4F7-20241205180328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601547
Report Date: 12/05/2024
Date Signed: 12/05/2024 06:04:05 PM

Document Has Been Signed on 12/05/2024 06:04 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LARAMIE MANOR DBA JMPA RESIDENTIAL CARE		FACILITY NUMBER:	197601547
ADMINISTRATOR/ DIRECTOR:	DINA PAMATMAT		FACILITY TYPE:	740
ADDRESS:	10151 LARAMIE AVENUE		TELEPHONE:	(818) 998-4940
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Dina Pamatman, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

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Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi, conducted unannounced annual visit. LPAs met with the Joseph Ponterrada, Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit.

At 2:00pm, LPAs conducted a physical plant tour with and the following was observed:

Kitchen: At approximately, 2:10pm toured the kitchen area and observed the fire extinguisher was last serviced on 05/17/2024. All knives were locked in a kitchen drawer and inaccessible to residents. Medications were observed locked in a kitchen cabinet. Furthermore, LPAs observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. At 2:15pm, LPAs observed unlocked medications placed in the refrigerator and accessible to residents in care. Facility is currently providing care to residents with Dementia.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. LPAs observed five (5) beds had 1/2 bed rail and only one (1) resident had a written doctors order on file. Bedroom #1 is designated for live-in staff. Upon entry into the staff room, LPAs observed multiple medications/vitamins in the drawer. LPAs also observed that the room was unlocked and all medications were accessible to residents in care.

Bathrooms: At 2:30pm LPAs observed all bathrooms are in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 120 degree Fahrenheit. LPAs observed appropriate grab bar and had non-skid mat. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LARAMIE MANOR DBA JMPA RESIDENTIAL CARE	FACILITY NUMBER: 197601547
	VISIT DATE: 12/05/2024

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Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Laundry area is located in a hallway by the room #5. All detergents were observed to be locked and inaccessible to residents in care.

Outside areas: LPAs toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for clients. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: At 2:50pm, LPAs observed detached garage door unlocked and various chemicals, paint and fuel was accessible to residents in care.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 3:45pm they were tested and observed to be operational.

Administrative: LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC500.

Deficiencies issued on LIC809-D during today's visit.

Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/05/2024 06:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LARAMIE MANOR DBA JMPA RESIDENTIAL CARE	FACILITY NUMBER: 197601547
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Postural Support: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and record review, the licensee did not comply with the section cited above by failing to obtain a written Doctor's order for 1/2 bedrail for four (4) out of five (5) residents, which poses an immediate health, safety to persons in care.
	POC Due Date: 12/07/2024
	Plan of Correction
1 2 3 4	License/Administrator will obtain a written Dr. order for 1/2 bedrails for all four (4) residents. Copies of orders must be submitted to LPA by POC date.

Section Cited

Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above by not ensuring medications in the refrigerator and the paint/fuel/chemicals in the garage are kept locked and inaccessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will need have an in-service training with all staff members regarding this deficiency and a proof of training shall be submitted to LPA bye 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.

Nichelle Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC809 (FAS) - (06/04)

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