197606349-11-15-2024-31-AS-PKHN-DB328R-20241115161046

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606349
Report Date: 11/15/2024
Date Signed: 11/15/2024 04:13:06 PM

Document Has Been Signed on 11/15/2024 04:13 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:	GARNER'S HOME CARE		FACILITY NUMBER:	197606349
ADMINISTRATOR/ DIRECTOR:	MARY JANE GARNER		FACILITY TYPE:	740
ADDRESS:	20959 STRATHERN STREET		TELEPHONE:	(818) 268-1403
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Rose Hugal - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	04:30 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	On 11/15/2024 at approximately 11:00am an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the caregiver Rose Hugal, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Administrator, Mary Jane Garner arrived and helped with physical plant tour and staff/residents files. During today's visit, LPA conducted a physical plant walk through, at approximately 11:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which five (5) may be Non-Ambulatory and one (1) bedridden for bedroom #2. Facility also has a hospice waiver for one (1) resident. There are five (5) bedrooms in the facility of which four (4) are designated for residents’ use. All bedrooms observed to be appropriately furnished except bedroom #4 had broken furniture/chest. All bedrooms have appropriate lighting. There are three (3) bathrooms in the facility of which two (2) are designated for residents’ use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 11:45 to be 107°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were off on all exit doors. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 1:00pm they were tested and observed to be operational. The facility has two (2) fire extinguishers that were last purchased on May 3rd, 2024. Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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

FACILITY NAME: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
	VISIT DATE: 11/15/2024

NARRATIVE

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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked drawer inaccessible to residents in care. Extra emergency food was properly stored inside the storage cabinet. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 12:00pm to be 70°F. No obstructions and or tripping hazards throughout the facility found.

MEDICATION: LPA observed centrally stored medication, facility staff/resident files, and First Aid kit locked in the kitchen cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Potentially dangerous items are kept inaccessible to residents in care. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift.

COMMON AREAS: LPA observed two (2) living rooms and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line, LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located in the separate closed door area next to the kitchen. LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area was available for residents at the front area of the house. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is no garage in the property.

FILE REVIEW: Between 12:00pm to 2:30pm, LPA reviewed records and files of three (3) residents and three (3)staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain assigned admission agreements and a medical assessment, and all other required documentarians.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
	VISIT DATE: 11/15/2024

NARRATIVE

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A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility.
Facility also provides activities to the residents.
An emergency exit plan/sketch along with other posting requirements are posted on the wall in the living room.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

LPA collected LIC500, LIC9020, copy of Administrator's certificate and Infection Control / Mitigation Plan. The Administrator stated that the facility currently does not have a Liability Insurance.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 04:13 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: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87705 Care of persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates: 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. LPA obseved the delayed egress alarms had been turned off and were not working which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to change the batteries and submit proof of working alarms to CCL by POC date.

Section Cited

1569.605 Liability insurance: coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.

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
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 04:13 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: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not comply with the section cited above as R1’s bedroom chest/drawer is broken, which poses a potential health and safety and personal right risk to residents in care.
	POC Due Date: 11/18/2024
	Plan of Correction
1 2 3 4	Administrator agreed to fix/replace R1’s drawer and submit copy of receipt/picture to LPA by POC 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.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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