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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607998
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:58:04 PM

Document Has Been Signed on 10/25/2022 04:58 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:ESPERANZA FACILITYFACILITY NUMBER:
197607998
ADMINISTRATOR:CHRISTIAN OLANOFACILITY TYPE:
735
ADDRESS:6328 QUARTZ AVETELEPHONE:
(818) 914-4335
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 4CENSUS: 4DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Ana AvilesTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. Upon arrival, staff notified the LPA that two (2) out of four (4) clients were not in the facility at the time of the visit as one (1) was working and one (1) was at school. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. However, the following items were found to be expired Raspberry Balsamic Vinegar 11/17/18, Coconut Vinegar 9/20/20, Cereal 6/21/22, Steal Cut Oats 11/24/21 and 8/12/21, Pancake Mix 3/27/21, Hot dog buns 10/22/22, White Bread 6/28/22, Wheat Bread 8/30/22. BEDROOMS: The client rooms were furnished appropriately; beds had with clean linens and rooms had sufficient lighting. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 3:39 p.m. and 3:42 p.m., water temperatures measured between 116.7 F and 116.9 F, which is within the required range of 105-120 degrees F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Fire extinguisher was observed to be full however did not have a proof of service or proof of purchase. The backyard had furniture and a covered area for resident use. The side gate door was self-latching but observed to be broken and the door was left open to allow access. A pool was observed with two gates both gates were locked, and the pool was inaccessible. Two locked storage sheds were observed, one contained personal belongings for staff and one contained cleaning supplies. Washer and dryer are located in the backyard. No cleaning supplies were observed to be accessible. The facility has a covered car port and no garage.

Continued on LIC 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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: ESPERANZA FACILITY
FACILITY NUMBER: 197607998
VISIT DATE: 10/25/2022
NARRATIVE
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INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry. Infection Control signs were observed throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation, and vaccine requirements. The facility managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The facility's procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC809-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2022 04:58 PM - It Cannot Be Edited


Created By: Elsie Campos On 10/25/2022 at 04:38 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: ESPERANZA FACILITY
FACILITY NUMBER: 197607998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as bread, cereal, oatmeal and dressings were observed to be expired which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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The Licensee agreed to do the following:
1. Dispose of identified expired foods immediatley. Plan of correction met at the time of the visit.
2. Audit all food both perishable and non perishable and exure that foods are labled correctly notify CCL no later than 10/28/22.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/25/2022 04:58 PM - It Cannot Be Edited


Created By: Elsie Campos On 10/25/2022 at 04:38 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: ESPERANZA FACILITY
FACILITY NUMBER: 197607998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as 1 out of 1 extinguisher did not have proof of service or purchase and LPA was unable to determine the expiration date, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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The Licensee Agreed to do the following:
1. Purchase a new fire extinguisher or service the existing fire extinguisher and provide proof to CCL no later than 10/28/22.
2. Keep prrof of purchase or service with fire extinguisher.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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