197606107-4-26-2022-31-AS-JMAZ-CDUQ6T-20220426115405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606107
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:54:51 AM

Document Has Been Signed on 04/26/2022 11:54 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	RICH-WAL CENTER #3, THE		FACILITY NUMBER:	197606107
ADMINISTRATOR:	SHIRLEY A. WALKER		FACILITY TYPE:	735
ADDRESS:	15832 BAHAMA STREET		TELEPHONE:	(818) 892-9258
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 5	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Maythe Vazques		TIME COMPLETED:	12:10 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

On 04/26/22 at 10:10 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conducted an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA’s temperature was taken. LPA Martinez later met with Administrator Shirley Walker via Facetime and the purpose of the visit was explained. A physical tour of the facility was conducted and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 10:45 a.m. and appear to be functional. Fire extinguisher has a service date of 08/06/2020. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. Facility has two living area where one is designated for an activity room. The facility has an attached room where there is an indoor pool. Pool is empty and room door is maintained locked. Clients Rooms: Facility has four (4) bedrooms which of three (3) are designated for client use. Facility has one live-in staff. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the clients. All rooms have adequate lighting. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for client's use. LPA observed all bathrooms to be clean and free of any hazards. The hot water was tested in both client’s bathrooms and were within regulations. All trash cans located in the bathrooms had tight fitting lids.

(Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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 3

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: RICH-WAL CENTER #3, THE	FACILITY NUMBER: 197606107
	VISIT DATE: 04/26/2022

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
26
27
28
29
30
31
32

Garage: There is an attached garage that is being used for laundry area and additional storage. There is a locked cabinet where all chemicals and cleaning supplies are kept. Garage area is maintained unlock when staff are helping with the laundry, but there are no hazards accessible to clients. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water in the outside area.

Administrator was not available to sign the report but designated staff Maythe Vazques to sign.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited. See 809-D. $500 Civil Penalty issued. Report signed and delivered. Appeal rights delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/26/2022 11:54 AM - It Cannot Be Edited

Created By: Joscelyn Martinez On 04/26/2022 at 11:20 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RICH-WAL CENTER #3, THE	FACILITY NUMBER: 197606107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance 80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Fire extinguisher tag was observed to have a service date of 08/06/2020
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring fire extinguisher was service within time which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2022
	Plan of Correction
1 2 3 4	Administrator will purchase a new fire extinguisher or have the current one service and ensure that the fire extinguisher is updated annually. Administrator will send proof of invoice to LPA via email.

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:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Joscelyn Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3