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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606622
Report Date: 11/10/2021
Date Signed: 11/10/2021 05:28:37 PM

Document Has Been Signed on 11/10/2021 05:28 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:STANWIN RESIDENTIAL CAREFACILITY NUMBER:
197606622
ADMINISTRATOR:MARY JANE C. MONTIANOFACILITY TYPE:
735
ADDRESS:9768 STANWIN AVENUETELEPHONE:
(747) 225-0382
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 6DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Jane MontianoTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Yelena Avetisyan, conducted an unannounced Required 1 year inspection at the facility. LPA was greeted by staff, Ronell Ocampo, who granted access to the facility. administrator Mary Jane C. Montiano arrived to the facility approximately 4:00 pm.

Approximately 2:15 pm LPA conducted a tour of the facility with the assistance of the staff

Infection control: Upon arrival, LPA was screened, however not asked to sign-in the visitors’ log. In addition, LPA was not asked all infection control questions. Proper signage was observed inside the hallway and in the restrooms. Hand sanitizer was also observed. LPA advised the administrator to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. LPA observed all trash can throughout the facility have fitted lids.
Kitchen: LPA toured the kitchen area and observed sufficient supplies of non-perishable food for a minimum of 1 week and perishable food for 2 days at the facility. All knives and sharp objects were observed in a locked drawer and inaccessible to clients in care. The fire extinguisher is located in the kitchen and was observed to be fully charged.

Smoke detectors/carbon monoxide. Smoke detectors are hard wired and battery operated and were located throughout the facility. At 3:25pm the smoke detectors were tested and observed to be operational. At 3:24 pm staff tested the carbon monoxide detector which was not operational. At 3:30 pm Staff changed the batter and retested the carbon monoxide detector which was operational.

Bedrooms: There are three (3) bedrooms designated for clients' use and have sufficient lighting. All bedrooms were not properly furnished. All rooms had a strong odor, While touring the residents rooms LPA observed the following: Broken blinds, closet doors cracked, flooring cracked, window panels, mirrors and furnishings dirty/dusty.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 11/10/2021 05:28 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 11/10/2021 at 04:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STANWIN RESIDENTIAL CARE
FACILITY NUMBER: 197606622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 by not having a designated visitation area and not ensuring that the physical plant is clean, safe, sanitary and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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Licensee will clean the clutter in the backyard and create an area to be used by clients and for visitation as required. Licensee administrator will conduct a walk through of the facility and create a maintenance log documenting all areas that need to be cleaned, repaired and furnishings that need to be replaced. Licensee will submit copy of the maintenance log with a written plan as to when and how the repairs will be completed. Licensee will send weekly updates to the LPA as repairs are completed.
Type B
Section Cited
CCR
80075(h)(2)
Health-Related Services
(h) There shall be at least one person capable of and responsible for communicating with emergency personnel in the facility at all times. The following information shall be readily available: (2) The name, address and telephone number of each emergency agency, including but not limited to the fire department, crisis center or paramedical unit. There shall be at least one medical resource available to be called at all times.

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 by not posting the required emergency agency phone numbers which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee/Administrator will review the regulation, create and post the required information. Licensee will submit copy of the created document and a photo that it has been posted at the facility as a 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/10/2021 05:28 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 11/10/2021 at 04:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STANWIN RESIDENTIAL CARE
FACILITY NUMBER: 197606622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.

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 by not having the required furnishing and ensuring the furniture is in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee/administrator will review the regulation and ensure that all clients have the required furnishings that are clean and in good repair. Licensee will submit photos of each resident room as POC.
Type B
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

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 by not conducting disaster drills as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee/Administrator will review the regulations, conduct the required drills. Licensee/Administrator will submit verification of the completed disaster drill 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: STANWIN RESIDENTIAL CARE
FACILITY NUMBER: 197606622
VISIT DATE: 11/10/2021
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Bathrooms: Bathroom located near the kitchen had broken mirror that staff used tape to repair, toilet paper holder broke, lights missing light bulbs. Bathroom in the hallway had toilet seat broken . Bathrooms were not properly supplied, LPA requested for staff to place paper towel in one bathroom and toiled paper in the second,
Common Areas: The facility maintains a comfortable temperature. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 3:00 pm LPA toured the outside area of the facility. LPA did not observe appropriate outdoor furniture, with a covered shaded area for clients. The backyard of the facility is completely cluttered and was padlocked by the licensee. LPA requested for the padlock to be removed. The Licensee agree to clean the backyard and create outdoor space for client use. There are no bodies of water

Medications: LPA observed medications are centrally stored and locked in the cabinet in the kitchen area, and inaccessible to clients in care.

File Reviews: From approximately 3:40 pm to 4:40 pm LPA conducted review of the resident and staff files. While reviewing the files LPA observed that staff used white out to change the dates on the appraisal needs and services plan for 4 of the 6 residents. LPA spoke with the administrator regarding this observation. LPA also observed admission agreements did not have addendums to reflect the rate change. Staff are also not completing the medication start date for 6 out of 6 clients on the centrally stored medication and destruction log. While reviewing staff files LPA observed that staff does not have the required annual training, proper medication training, infection control training. Licensee/Administrator agreed to provide staff with the required annual training including medication training.

Administrative: LPA requested for copy of liability insurance, surety bonds, administrator certificate and LIC 500 to be submitted to the LPA by 5:00 pm 11/11/2021.

Exit interview conducted, copy of report, citations and appeal rights emailed to the licensee.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/10/2021 05:28 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 11/10/2021 at 05:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STANWIN RESIDENTIAL CARE
FACILITY NUMBER: 197606622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, 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 interview the licensee did not comply with the section cited above by not ensuring staff receive proper infection control training and are fit tested for N95 masks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2021
Plan of Correction
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Licensee/Administrator and all staff will need to receive infection control training and N 95 fit testing. Completion of the training and verification of N95 fit testing will need to be submitted as POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
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