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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607438
Report Date: 05/19/2024
Date Signed: 05/19/2024 02:20:22 PM

Document Has Been Signed on 05/19/2024 02:20 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 PLACEFACILITY NUMBER:
197607438
ADMINISTRATOR/
DIRECTOR:		KATHY SHADEKO-ADEDIGBAFACILITY TYPE:
735
ADDRESS:2616 DAUNET AVENUETELEPHONE:
(805) 584-2995
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
05/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kathy AdedigbaTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 05/24/2023. When the LPA arrived, there were three (3) staff and four (4) clients present. LPA met with staff, and the Administrator, Kathy Adedigba arrived at 9:15 a.m., and at this time the reason for the visit was explained. Entrance interview conducted.

At 9:18 a.m., the LPA along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 9:30 a.m. Kitchen appliances were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Knives and sharps were observed locked and inaccessible in a kitchen cabinet. At 9:32 a.m., the hot water temperature measured at 113.5 degrees Fahrenheit.

COMMON AREAS: Living room and dining room furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. At 9:33 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be charged on 08/21/2023. LPA observed required postings throughout the common space.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BOROL PLACE
FACILITY NUMBER: 197607438
VISIT DATE: 05/19/2024
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Continued from LIC 809...

GARAGE: The garage is attached to the facility and was inaccessible to clients at the time of the visit. The washer and dryer were observed inside the garage. There was emergency food and water in the garage which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE).

BACKYARD: The backyard has a shaded area equipped with furniture for client use. Emergency exits and passageways were observed free of obstruction. LPA observed a locked shed with detergents and cleaning supplies inaccessible to clients in care. The facility has one (1) side gate with self-latching mechanism. No bodies of water noted at the time of the visit.

BEDROOMS: There are four (4) client bedroom. LPA observed the resident bedrooms to be furnished with linens, appropriate furnishings, and sufficient lighting. There is a designated staff bedroom on premises.

RESTROOMS: There are two (2) resident restrooms. Restrooms were clean with functional fixtures at the time of the visit. Restrooms were observed with grab bars. The bathrooms were sufficiently stocked with hand soap; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms. First bathroom measured at 113 degrees Fahrenheit at 9:20 a.m.; and the second bathroom measured 112.2 degrees Fahrenheit at 9:24 a.m.

RECORDS: Records review began at 9:40 a.m.; four (4) client records were reviewed for, but not limited to: needs and service plan, individual program plan (IPP), medical records with negative tb test results, admissions agreement, and consent forms.

Review of Client #1’s (C1’s) file revealed that a needs & service plan is missing from C1’s file, and one was not created for C1 prior to their admission to the facility.

Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BOROL PLACE
FACILITY NUMBER: 197607438
VISIT DATE: 05/19/2024
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Continued from LIC 809C...

Four (4) personnel records including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Files were complete. Administrator’s Certificate is active until 12/14/2025.

At 12:14 p.m., interview conducted with staff revealed that facility does not have a designated internet access device for client use at the time of the visit.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4I home.

The last emergency disaster drill took place on 04/25/2024.

MEDICATIONS: Medications review began at approximately 12:45 p.m.; medications are centrally stored in a locked filing cabinet by the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file.

At 1:10 p.m., C1’s PRN medication Lorazepam had one (1) tablet missing; however, there was no documentation of when PRN was administered to C1.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/19/2024 02:20 PM - It Cannot Be Edited


Created By: Martha Arroyo On 05/19/2024 at 01:56 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: 05/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and LPA observation, the licensee did not comply with the section cited above as the facility does not have an internet access device such as a computer, smart phone, tablet, or other device dedicated for client use, which poses a potential personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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The Administrator will have an internet access device designated to one facility only and it will be dedicated for client use.
Administrator will send proof to LPA before poc due date.
Type B
Section Cited
CCR
85068.2(b)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as C1 was admitted to the facility and needs & service plan was not completed prior to their admission to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will complete needs & service plana and submit proof to LPA before poc due date.
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:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/19/2024 02:20 PM - It Cannot Be Edited


Created By: Martha Arroyo On 05/19/2024 at 01:56 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: 05/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above as C1's PRN Lorazepam was missing one (1) tablet but no documentation of PRN given to C1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Administrator will conduct an in-house training will all staff on documenting PRNs and submit proof to LPA before poc due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2024


LIC809 (FAS) - (06/04)
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