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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606597
Report Date: 11/30/2022
Date Signed: 11/30/2022 04:10:42 PM


Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 11DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Teodora CambiadoTIME COMPLETED:
04:15 PM
NARRATIVE
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On 11/30/2022 at 9:30 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Spaeth arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPAs were greeted by Staff #1 (S1) who was not wearing a mask and granted access. LPA asked staff to call administrator. S1 called Teodora Cambiado. LPAs explained the reason for the visit. LPA Rios reviewed the Mitigation Plan approved 3/18/2021. The inspection tool was used to complete the visit.

At 9:35 a.m. LPAs and S1 began a physical tour of the facility and the following was observed:

LPAs observed a half door to the room where the medication and residents' files are kept was unlocked. A cabinet with residents' medications was unlocked. At 9:40 a.m. LPAs asked S1 why the cabinet to the medication was unlocked. S1 stated "I forgot to put this one." S1 was holding up a padlock and key in their hand. Bedrooms: There are ten (10) bedrooms designated for resident use. One (1) bedroom labeled # 2 was vacant. The resident rooms are furnished with required lighting, dresser, bed, and linens. One (1) bedroom labeled #7 had an unclean and ripped pillowcase. RESTROOMS: There are five (5) bathrooms. Two (2) out of the five (5) bathrooms were clean and sanitary. All bathroom had grab bars and non-skid mats. One (1) bathroom had a broken window. S1 stated it hadn't been broken for long.

LPAs observed four (4) fire extinguishers throughout the facility all four (4) have a tag with a last serviced date of 10/30/2021.

COMMON SPACES: The dining and living area were well lit, clean and clear of clutter. Furniture observed to be in good repair. LPA observed the thermostat at a comfortable temperature of 77°F. The backyard had furniture for resident use. At approximately 9:57 a.m. LPAs observed an outdoor laundry area. A washer and dryer were observed to be operable. LPAs observed an unlocked cabinet with laundry detergent accessible to residents.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597
VISIT DATE: 11/30/2022
NARRATIVE
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As LPAs made their way to the kitchen, LPAs observed a bed on the floor of the dining area. According to S1 he lays there at night to watch over residents that wonder. At 10:04 a.m. in the dining area LPAs observed a brown food substance on the ceiling measuring approximately 4 feet. KITCHEN: Knives and chemicals are locked and inaccessible in kitchen cabinet. Kitchen appliances were in operable condition. At 10:05 a.m. LPAs observed live roaches throughout the kitchen cabinets and kitchen counters. At 10:08 a.m. LPA observed two fridges with a lack of 2-day perishable food for 11 residents. The facility has a sufficient supply 7-day non-perishable food.

LPA observed smoked alarms throughout the facility. Smoke alarms interconnected. At 10:27 a.m. all smoke alarms were tested and functioned properly. S1 tried to locate the carbon monoxide detectors. S1 stated, "No, carbon monoxide."

At approximately 10:25 a.m. Teodora Cambiado met us at the facility. LPAs asked Dora if she is the administrator. Dora is not the administrator or licensee. LPAs asked Tedora to call the Licensee. LPAs spoke to Roda Garbato and she and Rex the Administrator are unavailable. Roda designated Teodora a staff to sign the report. At 10:39 a.m. LPAs asked Roda is she or Rex sent notice to the regional office that Rex would be unavailable out of the country for two weeks. Roda stated, "No, ma’am, I did not do that."

At 11:45 a.m. water temperature in the main bathroom was measured at 159.1 degrees Fahrenheit. LPA requested Teodora and S1 change the temperature immediately. Teodora and S1 did not know where the water heater was located. S1 said maintenance will have to do it.

At 3:00pm LPAs asked Teodora about the bed on the floor in the dining area. According to Teodora, S1 works days and nights but sleeps by the dining area to prevent residents from wondering.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22. Civil Penalty assessed and a $250 penalty issued (See LIC 421FC) Exit interview conducted, a copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation, the licensee did not comply with the section cited above in one out of five bathroom water temprature from sink faucet was measured by LPA at 159.1 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will immediately lower water temperature. Licensee shall submit a picture of water temprature on a themometer to LPA with required range of 105-120 degress fahrenheit by poc due date 12/01/2022.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)The following requirement shall apply to medications which are centerally stored:(2)Centerally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employess responsible for the supervison of centerally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in staff stating they forgot to lock the cabinet medication is stored in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Staff immediately locked the medication cabinet. Licensee shall conduct in-house training with Administrator and all staff regarding regulation above. A written statement acknowledging the completion of training shall be submitted to the LPA by e-mail by the POC 12/02/2022.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in four out of four fire extinguishers of the facility have not been serviced since 10/30/2021 and no carbon monoxide detectors were observed in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will purchase carbon monxide detectors for the facility. Licensee will purchase new fire extinguishers or have fire extinguishers serviced by POC due date 12/02/2022.
Type A
Section Cited
CCR
87309(a)
87309(a)Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not locking laundry detergent in a secure location which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Staff secured and locked laundry detergent immediately. Licensee shall conduct in-house training with Administrator and all staff regarding regulation mentioned above. A written statement acknowledging the completion of training submitted to the LPA by e-mail by the POC due date 12/01/2022.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555(b)The following food services requirement shall apply: (2) Supplies of ... perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two fridges with a lack of 2-days perishable food for 11 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee shall purchase a minimum of 2-days perishable food for 11 residents and submit a picture of food purchased and a pictue of the recipet by POC 12/02/2022.
Type A
Section Cited
CCR
87303(a)
87303(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
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Based on LPA observation, the licensee did not comply with the section cited above in not cleaning food off the dining area cieling, not providing a clean pillow case to resident, not fixing a broken window in residents' bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Staff cleaned food off the ceiling and provided resident with a clean pillowcase on todays visit. Licensee shall submit a picture of the window fixed by POC 12/02/2022. Licensee can reach out to LPA before POC due date if an extension is needed.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)(1)
80087(a)(1) Buildings and Grounds. Licensees shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview with Teodora, the licensee did not comply with the section above in, allowing live roaches though out the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee is to hire a professional exterminator to fumigate the entire facility to eliminate roaches and any other type of pest. The licensee will submit a copy of a scheduled pest control service for the initial visit by POC due date 12/02/2022
Type A
Section Cited
CCR
87411(a)
87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of the staff schedule (LIC 500), the licensee did not comply with the section cited above by not ensuring there is awake staff working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will remove the bed from the dining area and submit a piture to LPA. Licensee will also submit an updated LIC 500 and work schedule for December 2022 indicating awake staff for the night shift to LPA by POC due date 12/02/2022.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 11/30/2022 04:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: WESTPORT HOME
FACILITY NUMBER: 197606597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(F)
87470(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one staff #1 out of three not wearing a mask in the facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee shall conduct in-house training with Administrator and all staff regarding infection control mitigation plan. A written statement acknowledging the completion of training shall be signed by all staff shall be submitted to the LPA by the POC due date of 12/07/22.
Type B
Section Cited
CCR
87405(a)
87405(a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above in not informing regional office licensee and administrator will be unavailable and designated someone without the proper qualifications to be responsible of the facility in their absence which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Licensee will notify LPA by email when the administrator returns to the facility and have administrator review regulation mentioned above by POC due date 12/14/2022.

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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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