197606542-3-11-2024-31-AS-LCAS-D39SDS-20240311134739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606542
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:47:54 PM

Document Has Been Signed on 03/11/2024 01:47 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:	ADMIRABLE HOME CARE		FACILITY NUMBER:	197606542
ADMINISTRATOR:	JOSEFINA AMORSOLO		FACILITY TYPE:	740
ADDRESS:	43252 DARBY STREET		TELEPHONE:	(661) 946-1050
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	5	CENSUS: 1	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Cecilio Amorsolo		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA), Lorena Casillas, met with Caregiver Cecilio Amorsolo for an unannounced one (1) year Required visit for this facility.

At 10:00 am LPA arrived at the facility and was granted access by a Caregiver who then called the Administrator. The Administrator would not be able to attend as she is currently unavailable and assigned Caregiver Cecilio Amorsolo to sign the report.

A tour of the physical plant was conducted at 10:22 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying one (1) resident. Three (3) bedrooms are designated for staff use only. Facility is approved for four (4) ambulatory and two (2) non ambulatory, and currently there is approval for one (1) hospice waiver. LPA observed One (1) resident in their room watching TV.

LPA observed that there has been new construction converting the garage into living quarters however the facility sketch is not updated, and Community Care Licensing was not made aware prior to the changes. LPA advised caregiver that this will be a citation he agreed and stated that they were not aware that they were supposed to let Licensing know of the change.

Infection control: LPA reviewed facility mitigation plan (approved on 03/16/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted a tour of the kitchen around 10:25 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. Medications were locked in a cabinet located in the kitchen. There is one (1) fire extinguisher located in the kitchen and was observed to be full and last purchased on 03/11/2024.

Continued on 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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: ADMIRABLE HOME CARE	FACILITY NUMBER: 197606542
	VISIT DATE: 03/11/2024

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Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:20 am.

Bedrooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, a dresser, and sufficient lighting for each resident.

Bathrooms: LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. At 10:55 am the hot water was tested and measured within regulation at 107.4 degrees F.
Laundry: LPA observed chemicals/hazardous items located in the laundry room.

Garage: There is no garage. Area has been converted into living quarters for staff.

Outside Area: LPA toured the outside area of the facility at 11:00 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA conducted a file review of staff records to ensure compliance with licensing forms.

Medications: LPA and Caregiver reviewed medication and medication records for proper documentation.

Staff Interviews: At 11:40 am LPA interviewed staff.

Client Interviews: At 12:00 pm LPA interviewed client.

Administrative: Annual fees are current. LPA collected Certificate of Liability Insurance, LIC500, and Resident Roster.

Please see 809-D. Citation issued. Exit interview conducted. Appeals rights discussed and given. A copy of this report was provided.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 01:47 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: ADMIRABLE HOME CARE	FACILITY NUMBER: 197606542
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80086(a)

80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by failing to contact Community Care Licensing prior to new construction, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Administrator will submit a new facility sketch to LPA by email on 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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena Casillas	TELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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