197606909-11-22-2024-31-AS-PKHN-DB9UM7-20241122144154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 11/22/2024
Date Signed: 11/22/2024 02:43:10 PM

Document Has Been Signed on 11/22/2024 02:43 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA		FACILITY NUMBER:	197606909
ADMINISTRATOR/ DIRECTOR:	ANGELICA SERRANO		FACILITY TYPE:	735
ADDRESS:	22005 PARTHENIA AVENUE		TELEPHONE:	(747) 242-1038
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY: 5		CENSUS: 4	DATE:	11/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Shalom Eromosele-Caregiver		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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On 11/22/2024 at 10:15am. Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a Required Annual Inspection. LPA was greeted by the Caregiver Shalom Eromosele who granted access to the facility. Shalom called House Lead Jessica Sturkey and informed her the reason for the visit. Jessica Sturkey informed LPA that she will arrive shortly, however, the Administrator is in Palmdale office and won’t be able to be present during the inspection. LPA Khurshudyan reviewed the required postings on a wall by the entry and on the wall next to the kitchen. The inspection tool was used to complete the visit. The House Lead arrived at approximately 12:20pm.

At 10:45am. LPA along with Shalom began a physical plant tour of the facility and the following was observed by the LPA: This 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 non-ambulatory clients. Facility is operating level 4 clients.

Kitchen: LPA observed a seven-day supply of non-perishable food and a two day supply of perishable foods; properly stored and labeled. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records in a locked cabinet by the kitchen. LPA observed two (2) fire extinguishers one (1) is located by the kitchen and the second is in a hallway fully charged with a serviced date of 01/04/2024. A weekly menu was available.

Common Areas: These include the living areas and the dining areas. LPA observed dining, living and loft areas clean and clear of clutter with furniture in good repair. Dining and living room furniture sits the capacity of the facility. Walls, floors, windows, screens, ceiling fans, and blinds were clean and in good repair. At 12:35pm. LPA measured the room temperature to be 71 degrees Fahrenheit. There is a linen closet by bedroom #3 contained an adequate supply of fresh linens ready to use.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA	FACILITY NUMBER: 197606909
	VISIT DATE: 11/22/2024

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LPA observed a non-gated fireplace in the living room, and got informed that the fireplace is non operational. There was a television and various activities, games, board games stored inside the cabinet located in the living room.

Bedrooms: There are four (4) client bedrooms for single use. LPA observed bedrooms to be properly furnished with a beds, linens, night stand, a chair, drawers, closet, and adequate lighting. All bedrooms appeared organized and clean.

Bathroom: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in both bathrooms at approximately 12:00pm. and measured 106.9 degrees Fahrenheit. LPA also observed required signs on the bathroom walls, grab bars near the toilet and shower, and a non-skid mat in the shower.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by the a staff at 1:00pm. and were observed operational.

Laundry Room & Garage: LPA observed the garage is attached to the facility and has access from the kitchen area. The garage door was locked. 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.

Backyard: LPA observed all emergency exit paths were free from obstructions. Two (2) exit gates were unlocked with self-closing latches. The patio area has appropriate outdoor furniture for clients. There was a swing and basketball hoop for clients in care.

The facility vehicle was parked at the front of the house and ready for operation.

Staff/Client Interview: At 1:30pm-2:20pm. LPA conducted record reviews for nineteen (19) out of nineteen (19) staff files to insure compliance with licensing forms, and four (4) out four (4) client records were reviewed to insure compliance. Files were complete and updated.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA	FACILITY NUMBER: 197606909
	VISIT DATE: 11/22/2024

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Medications: At approximately 12:45pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the kitchen cabinet and inaccessible to clients in care. LPA observed First-aid kit is complete and has new manual. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with three (3) shifts and has three (3) staff members for each shift.

An emergency exit plan/sketch is posted along the hallway with other posting requirements.

LPAs collected LIC500, LIC9020.

No deficiency cited on todays visit. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC809 (FAS) - (06/04)

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