197607495-7-11-2022-29-AS-ECAS-CG8VVP-20220711164641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607495
Report Date: 07/11/2022
Date Signed: 07/11/2022 04:47:46 PM

Document Has Been Signed on 07/11/2022 04:47 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:	CHATEAU LE PETITE III		FACILITY NUMBER:	197607495
ADMINISTRATOR:	BELINDA DOLINSKY		FACILITY TYPE:	740
ADDRESS:	24312 CARIS STREET		TELEPHONE:	(818) 610-1082
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	07/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Bibi Castaneda-Caregiver		TIME COMPLETED:	04:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at approximately 1:45 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Staff Bibi Castaneda and explained the reason for the visit. The administrator was unavailable at the time of the visit and BIbi Castaneda was the designated staff to sign the report.

The LPA toured the physical plant areas inside and outside with Staff Bibi Castaneda to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:56 p.m. the LPA observed an unlocked and accessible medication cabinet containing centrally stored medications. At 1:59 p.m. the LPA observed an unlocked and accessible cabinet under the kitchen sink containing disinfectants and cleaning supplies.

BEDROOMS: The LPA observed seven resident bedrooms and one staff room. Six out of seven resident bedrooms have an exit to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. At 2:21 p.m. the LPA observed accessible ointments in resident bedroom #4 and resident bedroom #5.

RESTROOMS: Restrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA did not observe appropriate hand-washing signs in the restrooms. Water temperature measured between 124.3 degrees Fahrenheit and 124.8 degrees Fahrenheit between 2:17 p.m. and 2:26 p.m.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
	VISIT DATE: 07/11/2022

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COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Passageways were clean and clear of obstructions. A water fountain was observed in the backyard with about two inches of sitting water. The fountain was not running at the time of the visit. Facility has a designated visitation area located outside under a covered patio area with appropriate furniture and seating for residents. The LPA observed all the required postings in the entrance hallway that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Hand sanitizer was available for staff and resident use. Fire Extinguisher was last bought 8/15/2019. Staff was reminded that fire extinguishers are to be serviced or purchased on a yearly basis.

GARAGE: There is an attached garage containing cleaning supplies, additional Personal Protective Equipment (PPE) and incontinence supplies. The garage was unlocked with a single latch making it accessible to residents with a single turn. The keypad was not working at the time of the visit and required repair. Staff was reminded that it must be kept locked and inaccessible to residents at all times.

INFECTION CONTROL: The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed that staff are not conducting temperature checks upon entry as they do not have a working thermometer. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator continues to conduct testing, regardless of vaccination status. The facility’s policies and procedures as it pertains to infection control are adequate. The licensee is reminded that any and all cases of COVID-19 are to be reported to licensing timely and to continue following COVID-19 guidelines.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator and staff, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2022 04:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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, as water temperatures registered above 120 degrees Fahrenheit, which poses an immediate health and safetyrisk to persons in care.
	POC Due Date: 07/18/2022
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Adjust the water temperature and advise the LPA no later than 7/12/2022 2. Send a five-day temperature log to demonstrate that the temperature is regulated within range. Temperature log will be sent to the LPA no later than 7/18/2022

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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, as the cabinet for centrally stored medications was unlocked, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/12/2022
	Plan of Correction
1 2 3 4	The licensee has agreed to do the following: 1. Ensure that all centrally stored medications are locked up. Inform CCL as to when this is completed; no later than 7/12/2022. Plan of correction met at time of the 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2022 04:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 as the LPA observed accessible cleaning supplies, disinfectants and ointments, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 07/12/2022
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Secure all accessible items and notify CCL no later than 7/12/2022. Plan of correction met at time of the visit.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 07/11/2022 04:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 as the lock under the kithchen sink and lock on gargage door were in disrepair which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/18/2022
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Repair the lock for garage door ensuring that it locks appropritaley and provide proof to CCL no later than 7/18/2022.

Type B

Section Cited

CCR

87203

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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, as the fire extinguishers were last purchased 8/15/2019, which poses a potential health and safety risk to residents in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	The licensee agreed to do the following: 1. Have the extinguishers serviced or purchase a new one; submit proof to CCL by 7/15/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022

LIC809 (FAS) - (06/04)

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