197603946-9-3-2024-31-AS-LCAS-D8S2G4-20240903172231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603946
Report Date: 09/03/2024
Date Signed: 09/03/2024 05:24:03 PM

Document Has Been Signed on 09/03/2024 05:24 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	STRAWBERRY FIELDS		FACILITY NUMBER:	197603946
ADMINISTRATOR/ DIRECTOR:	GORY, MONICA		FACILITY TYPE:	740
ADDRESS:	434 E LANCASTER BLVD		TELEPHONE:	(661) 206-7925
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	09/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Monica Gory		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 (LPA) Lorena Casillas met with administrator Monica Gory for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:00 am and was greeted by a caregiver. Caregiver called administrator and LPA was informed that administrator was on their way. LPA informed the Administrator of the purpose of the visit via phone. Six (6) out of the six (6) residents were observed to be in their room sleeping, watching TV and/or resting. There is only one (1) staff member for care in the facility. The Administrator arrived at 02:45 pm. Infection control: LPA previously reviewed the facility mitigation plan (approved on 03/18/21) to make sure the licensee was following current infection control recommendations. A tour of the physical plant was conducted with caregiver at 10:20 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory, two (2) non-ambulatory, and a hospice waiver for one (1). Currently the facility has no residents on hospice. Food Inspection: LPA conducted a tour of the kitchen 10:20 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp objects being locked and inaccessible to residents in care. The Medication cabinet was in the kitchen and was observed to be locked and inaccessible to residents in care. Continued on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Lorena Casillas	TELEPHONE: 818-304-2695
	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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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Document Has Been Signed on 09/03/2024 05:24 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY FIELDS	FACILITY NUMBER: 197603946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, records review and interviews, Administrator did not ensure that the ambulatory status for two (2) residents was within the limitations of the license which allows two (2) non ambulatory residents this poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Licensee and Administrator agree to submit updated LIC200 form to CCL to increase non ambulatory capacity by POC due date and will email LPA proof of submission.

Type A

Section Cited

CCR

87204(b)

Limitations -Capacity and Ambulatory Status

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, record reviews, and interviews, Administrator did not ensure that two (2) residents that are non ambulatory reside in non ambulatory rooms. This poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Licensee and Administrator agree to submit updated LIC200 form to CCL to increase non ambulatory capacity with new facility sketch identifying non ambulatory rooms by POC due date and will email LPA proof of submission.

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) 596-4370
Lorena Casillas	TELEPHONE: 818-304-2695
	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/03/2024 05:24 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STRAWBERRY FIELDS	FACILITY NUMBER: 197603946
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Section Cited

CCR

87705(c)(4)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and records review, the licensee did not comply with the section cited above by only having one (1) caregiver to assist six (6) residents and not having additional staff to perform necessary work, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit a new LIC500 reflecting all shift coverage for facility that is adequate for all residents in care by email to LPA on POC due date. Administrator will remain at the facility to assist for the remainder of the shift while more staff is called in.

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.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Lorena Casillas	TELEPHONE: 818-304-2695
	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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

FACILITY NAME: STRAWBERRY FIELDS	FACILITY NUMBER: 197603946
	VISIT DATE: 09/03/2024

NARRATIVE

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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, a chair and sufficient lighting for each client. LPA observed the staff room to have a locked filing cabinet for staff and residents’ files. Currently the staff office has an extra freezer, and extra supplies.

Bathrooms: At 10:30 am LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriate wash your hands signs posted. Hot water was tested and measured within regulation at 115.0 degrees F.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 78°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:40 am. There are two (2) fire extinguishers, one (1) is in the kitchen and one (1) is in the hallway. The Fire extinguishers were observed to be full and last serviced on 10/29/2023. Laundry: LPA observed the laundry room to not have any chemicals or hazardous items. Cleaning supplies are kept locked in a hallway closet outside of laundry room.

Physical environment: LPA toured the outside area of the facility at 11:00 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises. Garage: LPA observed no garage.

Administrative: Annual fee is current. LIC 500, Client roster and Liability insurance will be emailed to LPA today.

Resident Files: LPA conducted a file review of resident records at 2:30 pm. Based on record review, facility is over capacity for non-ambulatory residents by one (1) resident. Civil penalty shall be issued. Facility will also be issued a citation for having one (1) non ambulatory resident in ambulatory rooms. Based on file review, a citation for not having sufficient staff will also be issued. Staff Files: LPA conducted a file review of staff records at 03:00 pm.

Medications: At 4:00 pm LPA and Administrator reviewed medication and medication records.

Citation issued. Civil Penalty issued (see LIC809-D). Appeals rights discussed and provided. Exit interview was conducted, and a copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

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