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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607998
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:37:14 AM

Document Has Been Signed on 10/22/2024 11:37 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESPERANZA FACILITYFACILITY NUMBER:
197607998
ADMINISTRATOR/
DIRECTOR:		CHRISTIAN OLANOFACILITY TYPE:
735
ADDRESS:6328 QUARTZ AVETELEPHONE:
(818) 914-4335
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 4CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Christian OlanoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Christian Olano arrived shortly thereafter.

The LPA and the staff 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: Knives and cleaning supplies are stored inaccessible in a kitchen drawer and cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 09:45AM, LPA observed five (5) cans of tuna of which three (3) expired 08/23/2024 and two (2) expired 06/30/2024, whipped cream expired 01/28/2024, pesto expired 11/16/2023, and habanero sauce expired 08/2022. Staff discarded all items immediately.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The restrooms were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between 110.0 – 118.0 degrees Fahrenheit, which is within the required range.

COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested at 10:16AM and all were operational at the time of the visit. LPA observed the fire extinguisher to be fully charged and last purchased 02/01/2024. The LPA observed required postings throughout the common space.

Report continued on LIC-809C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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Document Has Been Signed on 10/22/2024 11:37 AM - It Cannot Be Edited


Created By: Angela Barutyan On 10/22/2024 at 11:26 AM
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: 10/22/2024

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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Based on observation, the licensee did not comply with the section cited above as tuna, sauces, tomatoes, and lettuce were observed to be expired which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Staff discarded all expired items immediately. POC cleared during visit.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESPERANZA FACILITY
FACILITY NUMBER: 197607998
VISIT DATE: 10/22/2024
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OUTDOOR AREA: The backyard had furniture and a covered area for resident use. LPA observed an empty pool that was secured with two gates that were kept locked. A locked storage shed was observed containing cleaning supplies. The washer and dryer are located in the backyard. LPA observed an additional refrigerator and freezer in the backyard. At 10:08AM, LPA observed two (2) spoiled tomatoes, almond milk expired 10/19/2024, and spoiled romaine hearts. Staff discarded all items immediately. No cleaning supplies were observed to be accessible.

MEDICATIONS REVIEW: LPA began medication review at 10:17AM. Medications are centrally stored and locked in a cabinet in the kitchen area. LPA observed medications for two (2) clients which were observed to be properly documented on the centrally stored medications and destruction record.

RECORDS REVIEW: Records review began at 10:23AM. LPA observed all four (4) client records for documents including, but not limited to: care plans, medical records, admissions agreement, and consent forms. LPA observed three (3) personnel records for documents including, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All client and personnel files were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 06/01/2024.

INTERVIEWS: During today’s visit, LPA interviewed two (2) clients and two (2) staff.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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