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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607398
Report Date: 02/12/2025
Date Signed: 02/14/2025 11:31:49 AM

Document Has Been Signed on 02/14/2025 11:31 AM - 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:VIP ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197607398
ADMINISTRATOR/
DIRECTOR:		JERMARCUS DUMASFACILITY TYPE:
735
ADDRESS:37636 RUBY LANETELEPHONE:
(661) 533-3986
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 4DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:Jermarcus Dumas- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 2/12/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by Direct Support Staff members. LPA stated the reason for their visit. Administrator Jermarcus Dumas arrived shortly after to assist with today’s visit.

LPA asked for Census, Staff and Client Rosters. LPA conducted a physical plant tour at approximately 11:30 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. There is a designated staff room operated solely as an office. The facility has approved fire clearance for six (6) ambulatory clients of which two (2) may be non-ambulatory. This facility is operating at a Level IV-G and are vendor through North Los Angeles Regional Center. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas: Living rooms and dining room observed to be neat, clean, and organized. All rooms observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 72°F. Fire extinguisher located in the kitchen and dated 02/12/25. Required postings such as See/Say Something, Personal Rights and Rights of Individuals with Developmental Disabilities are located upon entrance. Fireplace: Observed to be covered and inaccessible to Clients. Working telephone observed.

Kitchen: Kitchen observed to be clean and inaccessible to pests. Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods were observed. Knives and sharps observed to be kept in a separate locked box within locked kitchen cabinet along with Medication. Kitchen appliances observed to be working and in proper condition. Review of medication revealed discrepancies (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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: VIP ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197607398
VISIT DATE: 02/12/2025
NARRATIVE
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Bedrooms: The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers stored in storage closet located in hallway’s passageway.

Bathrooms: Bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations at 112.3°F.

Laundry Room: The laundry room is located within a locked room leading towards the garage. LPA observed cleaning solutions, toxins, and laundry detergents within locked room. Laundry appliances observed to be working and in proper condition.

Garage: The garage can be accessed from inside the facility. LPA observed locked storage cabinet within the garage used to store emergency food and supplies.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for clients. There is no body of water in this facility. Extra freezer stocked with additional food for clients observed.

First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual. Facility files observed locked in staff room.

Smoke detectors and carbon monoxide observed to be working properly and were tested. Last Fire Drill conducted on 1/01/25.

Client/Staff Records: LPA conducted a complete file review of Client records. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

Citation issued refer to 809-D. Appeal rights given. No other immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 11:31 AM - It Cannot Be Edited


Created By: Angelica Segovia On 02/12/2025 at 12:55 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: VIP ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 197607398

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in (2) out of (4) Clients' medication was not given according to the physcian orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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The Licensee/Administrator will submit a plan of correction to LPA Segovia showcasing training on dispensing medication accordingly for all staff members. The written document will be submitted to CCL explaining how the facility will assure that the medication will be dispensed and medication records will be completed correctly.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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