197606909-12-8-2023-31-AS-NRED-CYBVHV-20231208152747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 12/08/2023
Date Signed: 12/08/2023 03:27:58 PM

Document Has Been Signed on 12/08/2023 03:27 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA		FACILITY NUMBER:	197606909
ADMINISTRATOR:	ANGELICA SERRANO		FACILITY TYPE:	735
ADDRESS:	22005 PARTHENIA AVENUE		TELEPHONE:	(818) 715-0977
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY: 5		CENSUS: 4	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jessica Sturkey		TIME COMPLETED:	03:25 PM

NARRATIVE

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At 10:40 a.m. on 12/08/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. LPA later met with the administrator designee and toured the facility inside and out at 1:00 p.m. No immediate health and safety hazards were observed during this visit.

The facility was last visited on 05/04/2022 for a case management visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 5 nonambulatory clients. Bedroom #1 is approved for 2 nonambulatory clients and Bedrooms #2, #3, and #4 are approved for 1 nonambulatory clients.

At 11:30 a.m. LPA conducted a file review. During today;s file review, it was discovered that five (05) out of five (05) staff did not have LIC 501, LIC 503, or LIC 9052 forms available for audit. A type B deficiency is cited on the attached LIC 809-D page.

At the main entrance, LPA observed a maintained front yard and a wheelchair lift in good condition. Postings observed inside the main entrance were the facility’s license, facility sketch with evacuation routes clearly labeled, client list, personal rights, grievance policy, emergency disaster plan, confidential complaint contacts, and COVID precautions.

All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. At approximately 1:20 p.m., two (02) out of two (02) dual-functioning smoke and carbon monoxide detectors were tested and operational. At approximately 1:30 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 12/21/2022. The facility uses surveillance cameras on the exterior.

At 1:25 p.m. LPA and Designee determined the facility vehicle to be operational and safe.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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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Document Has Been Signed on 12/08/2023 03:27 PM - It Cannot Be Edited

Created By: Nicholas Reed On 12/08/2023 at 02:43 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: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA	FACILITY NUMBER: 197606909
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in five (05) out of five (05) employee health screening forms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Licensee to ensure LIC 503, LIC 501, and LIC 9052 of all staff are retained at the facility and available for audit.

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:

Nicholas Reed

LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA	FACILITY NUMBER: 197606909
	VISIT DATE: 12/08/2023

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The garage was locked from the exterior. Disinfectants and hygiene supplies were stored and inaccessible in a separate cabinet in the garage. Also in the garage were emergency supplies of food and water, PPE supplies, medical equipment, and an extra freezer. A functioning washer and dryer were also stored in the garage.

Walls, floors, windows, screens, ceiling fans, and blinds were clean and in good repair. At 1:35 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. A linen closet by Bedroom #3 contained an adequate supply of fresh linens. A fireplace in the living room was not grated, but Designee informed that the gas line was cut off and non operational. The living room contained activities, games, and a television.

The facility has 4 bedrooms. 1 bedroom is shared and 3 are private. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:40 p.m. LPA measured the water temperature in Bathroom #2 to be 118.2 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods. The stove hood was clean. Appliances were in good condition. Sharps and cleaning solutions were locked below the counter. Medications and confidential records were locked in a separate closet by the kitchen. A weekly menu was posted as well.

LPA observed a shaded patio area in the rear of the facility. The patio contained a swing, a basketball court, a gardened area, and furniture in good condition. Ramps were in good condition as well.

At 1:50 p.m. today, Designee showed a complete first aid kit locked below the counter top. At 2:05 p.m., LPA tested the house phone to be operational.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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