197606622-11-14-2022-31-AS-TSMH-CL6UXB-20221114145805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606622
Report Date: 11/14/2022
Date Signed: 11/14/2022 02:59:33 PM

Document Has Been Signed on 11/14/2022 02:59 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 CARE		FACILITY NUMBER:	197606622
ADMINISTRATOR:	MARY JANE C. MONTIANO		FACILITY TYPE:	735
ADDRESS:	9768 STANWIN AVENUE		TELEPHONE:	(747) 225-0382
CITY:	ARLETA	STATE: CA	ZIP CODE:	91331
CAPACITY: 6		CENSUS: 5	DATE:	11/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mary Jane Montiano		TIME COMPLETED:	03:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility at 10:15 am. LPA rang doorbell, and no one answered. LPA contacted facility and spoke with administer. Administer states all residents at day program and she will arrive in approximately 30 minutes. Upon care staff arrival LPA disclosed the reason for this visit.

LPA conducted a tour of the physical plant at 10:45 am to ensure there are no health and safety hazards and facility follows Title 22 Regulations.

There are no bodies of water on facility premises. The facility has three (3) bedrooms and (2) two bathrooms for residents’ use. The bedrooms had adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets for residents’ comfort and safety.

There are two (2) bathrooms available for resident use. Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 117.8- and 124.4 -degrees Fahrenheit. Facility maintains a comfortable temperature for residents

Common areas were observed for the ability to safely serve the needs of residents. These included the living room and dining area. Common areas observed furnished appropriately. LPA observed a sufficient supply of linens and PPEs in hall closets.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. Sharps are locked in separate kitchen cabinet observed to be locked and inaccessible to residents in care.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: STANWIN RESIDENTIAL CARE	FACILITY NUMBER: 197606622
	VISIT DATE: 11/14/2022

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(Cont. from 809)

Resident medication stored in livingroom in locker-type storage. Observed to be locked and inacessible to residents.The first aid kits located in livingroom next to medication locker observed to be stocked.

Laundry room appliances observed to be functional. Extra toiletries stored in cabinets above washer and dryer. Toxins locked in staff room. Staff room observed to be locked and inaccessible to residents. Smoke alarms and carbon monoxide detectors were present and function properly at time of visit. The fire extinguisher located in kitchen observed to be charged.

Backyard and facility grounds were cluttered. The Licensee agree to clean the backyard and grounds and make available for residents’ use.

Citations were issued and recorded on LIC809D.

Exit interview conducted and copy of report given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2022 02:59 PM - It Cannot Be Edited

Created By: Tihesha Smith On 11/14/2022 at 01:39 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: 11/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

(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 vistors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above by not ensuring the physical plant grounds and walkways are clean, safe, and in good repair which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/18/2022
	Plan of Correction
1 2 3 4	Licensee will clear the clutter in the backyard, walkways and ensure areas are clean and available for use at all times by residents in care. Licensee/administrator will provide LPA a log of areas/items that require declutter, removal (or repair) or cleaning by 11/18/22. A plan detailing the process, when the declutter project will be completed, and weekly updates also due:11/18/22

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:

Naira Margaryan

LICENSING EVALUATOR NAME:

Tihesha Smith

LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC809 (FAS) - (06/04)

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