197608161-11-21-2022-31-AS-ERIS-CLDSUV-20221121131145

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608161
Report Date: 11/21/2022
Date Signed: 11/21/2022 03:41:53 PM

Document Has Been Signed on 11/21/2022 03:41 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/21/2022 03:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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	This is an amended report which excludes confidential names of residents and staff. On 11/21/2022 at 9:00 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an Annual Required visit and inspection. LPA Rios was greeted by staff #1 (S1) who granted access. Once inside staff #2 (S2) checked LPA's temperature. S2 asked LPA to sign in. LPA explained to S1 and S2 reason for the visit and asked S1 to inform Administrator LPA was at the facility. Administrator Reynaldo Del Rosario and Jesselyn Del Rosario designed to signed this report joined us shortly after. At 9:05 a.m. LPA took a tour of the physical plant. Required postings were observed in the entry area. There are carbon monoxide detectors that function properly. The fire extinguisher is located in the kitchen. The fire extinguisher was observed to be fully charged. LPA observed facility thermostat at 75 degrees Fahrenheit. Smoke detectors are hard wired and interconnected. Administrator tested smoke alarms at 10:56 a.m. and were functioning properly. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Two doors leading to the laundry room one from the kitchen and one from a full bathroom have no lock and LPA observed a locked two door closet where the washer and dryer and laundry detergent are kept. Bathrooms: There are three (3) full bathrooms and one (1) with a toilet and sink. The three (3) full bathroom are designated for residents' use. The bathroom with a toilet and sink located in a resident's room is for private use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110 degrees Fahrenheit in one (1) out of the three (3) full bathrooms. Extra linins are stored in the hallway bathroom.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TITA GUEST HOUSE	FACILITY NUMBER: 197608161
	VISIT DATE: 11/21/2022

NARRATIVE

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This is an amended report which excludes confidential names of residents and staff.

Bedrooms: There are five (5) bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Review of the facility fire clearance and facility sketch has a room designated as a staff master bedroom and not a bedroom for resident. LPA observed a ambulatory resident living in room 5. LPA asked administrator if they had and updated facility sketch and clearance. Administrator could only show LPA the facility sketch on the facility wall by the kitchen designating room as staff room only.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. LPA observed 3 sheds and a back house in the backyard. Three (3) out of the three (3) sheds are being used for storage. LPA opened the door to the back house on the far back right of the yard and observed a person inside in bed. LPA asked the person who they were. The person said, "I work the night shift." LPA asked for staff #3 (S3) name.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

No deficiency cited. Exit Interview Conducted / Appeal Rights provided / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/21/2022 01:13 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TITA GUEST HOUSE	FACILITY NUMBER: 197608161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202(a)All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in one (1) out of five (5) bedrooms. Bedroom 5 has a resident in the room which according to fire clearance/facility sketch is designated as a staff master bedroom and not as a resident's bedroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2022
	Plan of Correction
1 2 3 4	Administrator will move resident immediately and submit picture of empty room to LPA by POC date 11/22/2022.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC809 (FAS) - (06/04)

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