197607345-12-18-2023-31-AS-MSPH-CYMUFF-20231218143240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607345
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:32:49 PM

Document Has Been Signed on 12/18/2023 02:32 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:	IVAN BANNER BOARDING CARE		FACILITY NUMBER:	197607345
ADMINISTRATOR:	CYNTHIA TAYLOR		FACILITY TYPE:	740
ADDRESS:	39409 DAYLILY PLACE		TELEPHONE:	(661) 267-0779
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	12/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Donald Feagin		TIME COMPLETED:	01:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/18/2023. LPA was greeted by the caregiver. The facility is licensed for six ambulatory residents and there are five residents living in the facility. Three residents were attending an adult day program and two were in the facility during LPAs inspection.

LPA Spaeth and the Administrator began the tour at 9:40 am until 10:13 am. LPA observed the following:

Common areas – The living room and family room contained comfortable seating. The dining room contained a dining room table and chairs.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. A fire extinguisher was located in the kitchen area.

Pantry Room - The pantry room was locked and contained canned goods on one side of the room and cleaning solutions on the other side of the room. The washer and dryer were located in the pantry room.

Garage – The garage was locked.

Resident Rooms - LPA observed the resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers.

Medications - The medications were locked in a two drawer cabinet located in the dining room.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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

FACILITY NAME: IVAN BANNER BOARDING CARE	FACILITY NUMBER: 197607345
	VISIT DATE: 12/18/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Bathrooms – LPA observed the bathroom which contained contained hand soap, paper towels, and covered trash cans..

Water Temperature – LPA Spaeth tested the water at 10:13 am and was 117.0 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 10:10 am and were operable.

Backyard - LPA observed the backyard which has a shaded area. The gate leading from the backyard to the front yard was not locked.

LPA reviewed client records at 10:25 am until 11:00 am. LPA also reviewed staff records at 11:00 am until 11:20 am.

Based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/18/2023 02:32 PM - It Cannot Be Edited

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: IVAN BANNER BOARDING CARE	FACILITY NUMBER: 197607345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in two out of two staff members did not have an updated CPR and first aid training. Both staff members' training expried as of 1/12/2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Staff will complete the training and forward a copy of the completion of training certificate to LPA Spaeth via email.

Type A

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's review of residents' files, the licensee did not comply with the section cited above in two out of five residents' files did not contain the Physician's Assessment report which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	Staff will forward a copy of the Medical Assessment Reports for R1 and R1 via email to LPA Spaeth

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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3