<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197607438
Report Date:
05/24/2023
Date Signed:
08/25/2023 04:45:46 PM
Document Has Been Signed on
08/25/2023 04:45 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
CCLD Regional Office
,
21731 VENTURA BLVD. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
ADMINISTRATOR:
KATHY SHADEKO-ADEDIGBA
FACILITY TYPE:
735
ADDRESS:
2616 DAUNET AVENUE
TELEPHONE:
(805) 584-2995
CITY:
SIMI VALLEY
STATE:
CA
ZIP CODE:
93065
CAPACITY:
4
CENSUS:
4
DATE:
05/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:47 AM
MET WITH:
Isaac Adeleke, Assistant Administrator
TIME COMPLETED:
06:00 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) Zabel Chochian conducted an unannounced Required Annual visit and met with staff. Upon arrival LPA observed three (3) staff on duty and one (1) client in the home. Reason for visit was explained. Staff contacted Administrator and Assistant Administrator Isaac Adeleke. Administrators both arrived at approximately 12pm.
Facility is a level 4G home, vendored by Tri-Counties Regional Center serving developmentally disabled clients. Two clients require 1:1 staffing.
A tour of the physical plant was conducted with Administrator at approximately (approx.) 12pm. Smoke and carbon monoxide detectors tested and all are operable at this time. Facility has two full bathrooms designated for client use. Hot water temperature tested in one of two bathrooms (back to back) at 110 degrees. Bathrooms were observed to be in sanitary and operating condition. However, there is damage to the baseboard behind the toilet and toilet seat observed discolored. Supply of linens, towels and toiletries observed. There are five (5) bedrooms total (one bedroom for staff use). Client #4's bed and night stand observed broken at approx. 12pm. Bed and night stand needs to be replaced. Client #2's chair in room is broken (fix or replace chair). Client #3 needs chair in room. Common areas included the two living rooms that were checked: flooring and baseboard in the first living room by the lower vent observed in disrepair. Overall facility walls and baseboards of the home need to be cleaned and kept in good standing. Staff room exit sliding door screen observed at approx. 12:10pm to be torn. Screen needs to be repaired or placed.
LPA observed sharps, detergents and chemicals locked and inaccessible to clients. Sharps are kept in a locked cabinet next to the kitchen sink. Facility has sufficient two (2) day perishable and seven (7) nonperishable food supplies. Fire extinguisher in the kitchen last inspected 08/24/2022. The facility maintains a comfortable indoor temperature. The outer physical plant was clear and free of obstruction.
SUPERVISORS NAME
:
Desaree Perera
LICENSING EVALUATOR NAME
:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
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
6
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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
VISIT DATE:
05/24/2023
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
Client and staff records reviewed at approximately 1:15-3pm. LPA reviewed all clients’ records for updated Needs and Services plans/ Individual Program Plan (IPP), medical assessments, admission agreements, and all other pertinent documents in their file. P&I funds also reviewed balanced according to balance record. Staff records reviewed for current first aid certification, health screening documentation, criminal record clearance and other training. Staff files are current up to date with required documents and training.
Medications observed in a locked filing cabinet next to the dining table in the kitchen. Random sample of (2) clients medications and records reviewed from approx. 3pm-4:30pm. Review of the medications and records for two (2) out of four (4) clients revealed that Administrator did not have on file a Prescription and nonprescription (PRN) authorization letter for client #1 and client #3. Administrator agrees to audit all clients medications and records and obtain the PRN authorization letter and maintain a PRN log for the clients.
First aid kit observed complete with manual at approx. 4:45pm. Assistant Administrator could not locate the facility Emergency Disaster plan during the visit today.
Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8 following deficiencies are cited (see 809D). Exit interview conducted, appeal rights explained and copy of report provided.
SUPERVISORS NAME
:
Desaree Perera
LICENSING EVALUATOR NAME
:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
08/25/2023 04:45 PM
- It Cannot Be Edited
Created By:
Zabel Chochian
On
05/24/2023
at
04:37 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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that the living room floor and wall baseboard by the vent was in disrepair; also bathroom toilet seat observed with stained or peeled paint; wall/baseboard behind toilet needs to be repaired. Overall facility walls, flooring and baseboards need to be cleaned and in good repair.
This poses/posed a potential, health safety or personal rights risk to persons in care.
POC Due Date:
06/07/2023
Plan of Correction
1
2
3
4
Administrator agreed to make all repairs within two weeks. Submit photos by 6/7/2023.
Type B
Section Cited
CCR
85087(a)(3)(A)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements, garages, storage areas, and sheds, or similar detached buildings.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above - matress and staff clothing observed in a storage space located in the garage. Administrator stated that the space is used by staff to rest during the day.
This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/24/2023
Plan of Correction
1
2
3
4
Administrator remove matress from the storage area and will not allow staff to use this area for sleeping/resting.
Area observed cleared out during visit.
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:
Desaree Perera
LICENSING EVALUATOR NAME:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
08/25/2023 04:45 PM
- It Cannot Be Edited
Created By:
Zabel Chochian
On
05/24/2023
at
04:37 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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Staff room sliding door screen observed in disrepair (torn). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/07/2023
Plan of Correction
1
2
3
4
Administrator agrees to have the screen repaired or replaced.
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Bed used by client #4 observed broken. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/26/2023
Plan of Correction
1
2
3
4
Administrator stated that they will replace broken bed for client #3. Submit photo of new bed by 5/26/2023.
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:
Desaree Perera
LICENSING EVALUATOR NAME:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
08/25/2023 04:45 PM
- It Cannot Be Edited
Created By:
Zabel Chochian
On
05/24/2023
at
04:37 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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Client #2's chair needs to be replaced with stable chair. Client 3's room was missing a chair. This poses/posed a potential personal rights risk to persons in care.
POC Due Date:
05/26/2023
Plan of Correction
1
2
3
4
Administrator agreed to provide a chair for client #3 and replace client #2's chair. Submit photo by 5/26/2023.
Type B
Section Cited
CCR
80075(b)(5)
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:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review and interview with staff, the licensee did not comply with the section cited above . Client #1 and Client #3 take PRN medication and did not have a PRN authorization letteron file. This poses/posed a potential health, safety risk to persons in care.
POC Due Date:
05/31/2023
Plan of Correction
1
2
3
4
Administrator shall obtain a PRN authorization letter for all clients with PRN medication. Also Administrator shall develop a PRN log to document medication dispensed according to regulation. Submit copy of the PRN authorization letter and log by 5/31/2023.
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:
Desaree Perera
LICENSING EVALUATOR NAME:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
08/25/2023 04:45 PM
- It Cannot Be Edited
Created By:
Zabel Chochian
On
05/24/2023
at
05:32 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. #250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BOROL PLACE
FACILITY NUMBER:
197607438
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above. Assistant Administrator could not locate the facility Emergency Disaster record during todays visit. This poses/posed a potential health, safety rights risk to persons in care.
POC Due Date:
05/26/2023
Plan of Correction
1
2
3
4
Administratro shall locate and maintain a copy of the facilities Emergency Disaster record at the facility. Provide copy to LPA by 05/26/2023.
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:
Desaree Perera
LICENSING EVALUATOR NAME:
Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
6
of
6