197606341-10-12-2023-31-AS-MAGN-CWJLBK-20231012083653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606341
Report Date: 09/14/2023
Date Signed: 10/12/2023 08:37:56 AM

Document Has Been Signed on 10/12/2023 08:37 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LILY OF THE VALLEY		FACILITY NUMBER:	197606341
ADMINISTRATOR:	NATALIA L. ESPINO		FACILITY TYPE:	740
ADDRESS:	8618 BOTHWELL ROAD		TELEPHONE:	(818) 993-7800
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 2	DATE:	09/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rodolfo Espino- Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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On 09/14/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Rodolfo Espino. A tour of the physical plant was conducted at 10:15AM. The facility has 6 bedrooms. Bedrooms: Five (5) bedrooms designated for residents' use and (1) bedroom designated for staff. All bedrooms were clean, properly furnished and had sufficient lighting.
Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. LPA observed medication cabinet to be locked and inaccessible to residents. The living room has a television and comfortable furniture. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed that sharp objects were stored in locked drawers and cabinets. LPA observed fully stocked first aid kit in the kitchen the fire extinguisher purchased date 08/24/23. LPA found a sufficient amount of perishable and non-perishable food at the facility. Temperature: Facility maintains a comfortable temperature of 80 degrees Fahrenheit. Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom in hallway which is the main and two (2) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. All chemical cleaners were locked under the sink cabinet. Laundry Area: located through the kitchen. Appliances observed to be in good repair. All cabinets were locked and thus laundry detergents were inaccessible to residents. Backyard Area: There is a clean covered shaded area in the back yard and there is a pool which has a gate and is kept locked and inaccessible to residents in care. LPA also observed another room outside in the backyard next to the pool that has a hospital bed and a private bathroom. This room was not indicated on the facility sketch during the application process, which posed a potential health and safety issue for residents in care.Garage: LPA observed the garage been converted to a room with private bathroom. Review of facility sketch does not indicate that there is a room created in the garage. Interview with administrator revealed that the room was built during COVID for staff for isolation in case of contact. During records review LPA observed Tramadol medication over the number that stated on the container. Interview with administrator revealed that Administrator has transferred old Tramadol medication to the new container. Exit interview conducted and a copy of the report and appeal rights were provided. Deficiency was cited on 809D.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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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Document Has Been Signed on 10/12/2023 08:37 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LILY OF THE VALLEY	FACILITY NUMBER: 197606341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)(7)(A)

This requirement is not met as evidenced by: This requirement is not met as evidenced by:Based on LPA's observation on 09/14/2023 there were an additional 2 rooms created by the Licensee which was not reflected on the facility sketch during the application process, which posed a potential health and safety issue for residents in care.
	Deficient Practice Statement
1 2 3 4	...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions, of the following: Building(s) to be occupied, including a floor plan that describes the capacities of the buildings...
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Licensee aggress to submit and LIC200 and updated facility sketch indicating a change in facility floor plan by or before POC due date

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 08:37 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LILY OF THE VALLEY	FACILITY NUMBER: 197606341
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. LPA observed a bottle of Tramadol over the number of bills. Administrator has transfer old bills to new container of Tramadol which poses an immediate risk to residents in care.
	POC Due Date: 09/21/2023
	Plan of Correction
1 2 3 4	Administrator will provide proof of medication training for all staff.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC809 (FAS) - (06/04)

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