197606349-3-3-2024-31-AS-JGTN-D2ZW2V-20240303155458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606349
Report Date: 03/03/2024
Date Signed: 03/03/2024 04:13:12 PM

Document Has Been Signed on 03/03/2024 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARNER'S HOME CARE		FACILITY NUMBER:	197606349
ADMINISTRATOR:	MARY JANE GARNER		FACILITY TYPE:	740
ADDRESS:	20959 STRATHERN STREET		TELEPHONE:	(818) 268-1403
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 4	DATE:	03/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Mary Jane Garner - Administrator		TIME COMPLETED:	04:00 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) Gary Tan, met with Administrator Mary Jane Garner for a One (1) year required visit for this facility. A tour of the physical plant was conducted at 12:30 PM and the following was noted: There is only one entrance being utilized at the facility and must pass through a gate before reaching the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front yard inside the gate. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and three (3) bathrooms currently occupying four (4) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden. Hospice waiver for one (1) resident. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. Dual smoke and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the kitchen and was observed to be full and last inspected on 05/01/23. The front yard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 9099-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

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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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: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
	VISIT DATE: 03/03/2024

NARRATIVE

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(continued from LIC 809)

There is no garage at the facility only car ports on the front. The front yard has locked storage cabinets for all equipment and tools and other supplies. Laundry room is located adjacent to the kitchen and was observed to be locked. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in a cabinet in the laundry room.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at a range of 117.2°F to 119.1°F Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed. Resident #1 (R1) has a diagnosis of dementia and no current Medical assessment on file. Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 02/01/24. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2024 04:24 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/18/2024 08:36 AM

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: GARNER'S HOME CARE	FACILITY NUMBER: 197606349
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 4 residents' records reviewed, R1 has a diagnosis of dementia and no current medical assessment onf file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain a new medical assessment of R1 and submit a copy to CCL on before the 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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2024

LIC809 (FAS) - (06/04)

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