197602356-9-29-2023-31-AS-MSPH-CW5VWT-20230929164826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602356
Report Date: 09/29/2023
Date Signed: 09/29/2023 04:49:10 PM

Document Has Been Signed on 09/29/2023 04:49 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANA RESIDENTIAL CARE		FACILITY NUMBER:	197602356
ADMINISTRATOR:	SMITH, WANDA		FACILITY TYPE:	740
ADDRESS:	1046 EAST LANCASTER BOULVARD		TELEPHONE:	(661) 949-0151
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	6	CENSUS: 3	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Ashlee		TIME 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 Analyst Melissa Spaeth conducted an unannounced annual visit on 9/29/2023. LPA was greeted by the caregiver and stated the purpose of the visit. The caregiver confirmed there are three clients living at the facility. The facility is licensed for four ambulatory and two non-ambulatory residents. The Administrator arrived at 1:35 pm. LPA and Caregiver began the tour at 1:30 pm until 2:00 pm. LPA observed the following: Kitchen – LPA observed the kitchen area was neat and clean. LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. The knives were locked in a kitchen cabinet. The fire extinguisher was located nearr the kitchen. Common areas – LPA observed the living room/dining room contained comfortable seating, a dining room table, and chairs. The family room contained comfortable seating and a television. Hallway - LPA observed the locked hallway closet which contained residents' medication. There was a cabinet which contained clean linens. Garage – The garage was locked and contained the cleaning solutions, additional hygiene items, and additional refrigerator. Laundry Area – The washer and dryer were in the laundry area. A locked cabinet above the washer contained the first aide kit and additional first aid supplies.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA RESIDENTIAL CARE	FACILITY NUMBER: 197602356
	VISIT DATE: 09/29/2023

NARRATIVE

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Bathrooms – LPA observed the two bathrooms. Both bathrooms contained hand soap, paper towels, slip resistant mats, grab bars and covered trash cans.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 2:00 pm and were operable.

Backyard - LPA observed the backyard which has a shaded area with seating. LPA observed the pool has been filled in with dirt.

LPA reviewed client records at 2:25 pm until 2:50 pm. LPA observed a caregiver does not have the required CPR and first aid training. LPA viewed resident's medications at 3:30 pm until 3:45 pm.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to caregiver.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/29/2023 04:49 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA RESIDENTIAL CARE	FACILITY NUMBER: 197602356
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above in one of two persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	Administrator will complete the CPR and first aid training.

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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