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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 08/29/2019
Date Signed: 08/29/2019 12:26:23 PM

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:PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIAFACILITY NUMBER:
197606909
ADMINISTRATOR:ANDREA DEVERSFACILITY TYPE:
735
ADDRESS:22005 PARTHENIA AVENUETELEPHONE:
(818) 715-0977
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:5CENSUS: 4DATE:
08/29/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brandy MaynardTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz and CSS Cristina Perez conducted an unannounced case management visit on this day. LPA was greeted by staff and given a tour of the facility at 9:00am with Brandy Maynard. The facility is a single-story home consisting of a living room, dining room, kitchen, office, 4 client bedrooms, 2 bathrooms, and a garage/ laundry area. There is a backyard and patio area which wraps around and exits on both sides of the house.
-LPA inspected the clients' rooms, observing them to be appropriately furnished. Bathrooms were sanitary and contained working fixtures. Hot water temperature measured between 105- and 120-degrees Fahrenheit. The kitchen contained working appliances and an adequate supply of perishable and non-perishable foods. Knives, cleaning supplies and other potentially hazardous items were secured and inaccessible. Common areas were appropriately furnished as was the outdoor patio area. AT 9:20am LPA observed the kitchen cabinets, living room wall, and other common area appliances to be dirty and in need of cleaning. At 9:30am LPA observed a pile of trash boxes to be sitting along the facility wall and the recycling bin lid to be broken. The garage and laundry area are used for storage. LPA observed the fire extinguishers to be charged, emergency disaster plan posted, and smoke/ carbon monoxide detectors functional. The last emergency drill was conducted on 6/18/19.

LPA began reviewing facility files at 10:00 am. Required documents are displayed throughout the facility. 4/4 client files were reviewed, and all appeared to be complete and current. Personal and Incidental funds were reviewed, and the balance was consistent with the ledger and receipts on file. LPA discussed the facility’s P&I fund policy with administrator to address concerns raised by resident 1 (R1) during an unrelated complaint visit conducted on 8/22/19 for complaint #31-AS-20190613111558. Facility administrator confirmed the explanation given to LPA and CSS on 8/22/19 by administrator and regional manager, that the company’s policy is for residents to spend down the amount of P&I funds currently at the facility before receiving another $200 allotment.
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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 3
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: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909
VISIT DATE: 08/29/2019
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Administrator stated that residents could make specific requests for items exceeding $200 at any time, but the full $200 of regular P&I funds must be spent down before requesting more money for regular expenditures of less than $200.

Medications are centrally stored and secured; a random selection was reviewed at 11:00am and no deficiencies observed at this time. LPA could not finish reviewing staff files during this visit due to time constraints.

Report reviewed, signed, and delivered. Exit interview conducted, appeal rights given, deficiencies on 809D.
SUPERVISOR'S NAME: Jill NakataTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2019
Section Cited

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85072(b)The licensee shall insure that each client is accorded the following personal rights. (7)To possess and control his/her own cash resources.



This requirement is not met as evidenced by:
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Based on client and administartor interviews, the facility failed to ensure that R1's P&I funds were readily accessible and available for his use which poses an immediate risk to the personal rights of residents.
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Type B
09/05/2019
Section Cited

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80087(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:
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Based on observations, facility failed to ensure that the facility common areas, including livng room walls, kitchen cabinets and outside trash area, are clean which poses a potential risk to clients.
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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: Jill NakataTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3