197608161-12-8-2024-31-AS-JGTN-DBRSHV-20241208125410

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608161
Report Date: 12/08/2024
Date Signed: 12/08/2024 12:54:41 PM

Document Has Been Signed on 12/08/2024 12:54 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TITA GUEST HOUSE		FACILITY NUMBER:	197608161
ADMINISTRATOR/ DIRECTOR:	REYNALDO DEL ROSARIO		FACILITY TYPE:	740
ADDRESS:	8437 VANALDEN AVENUE		TELEPHONE:	(818) 775-9914
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Catherine Del Rosario - Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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	Licensing Program Analyst (LPA) Gary Tan met with staff Rexelon Gaurano who called Assistant Administrator Catherine Del Rosario for a One (1) year required visit for this facility. Assistant Administrator Del Rosario arrived twenty (20) minutes later. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:25 AM and the following was noted: There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) residents. An additional one (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory resident, one (1) of which maybe bedridden on rooms 1-4. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. Dual smoke/carbon monoxide alarms were tested and observed to be operational. There is a fire extinguisher located in the kitchen and observed to be full and last bought on The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is an structure at the backyard and two (2) locked tool sheds at the far end of the backyard. (continued on LIC 9099-C)

Troy Agard	TELEPHONE: (818) 596-4342
Jose Gary Tan	TELEPHONE: (323) 213-1149
	DATE: 12/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TITA GUEST HOUSE	FACILITY NUMBER: 197608161
	VISIT DATE: 12/08/2024

NARRATIVE

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The garage and was converted into offices for the staff. The offices were locked during visit. It is also being used as storage for miscellaneous supplies. Laundry room is located adjacent to the kitchen going to the rear end/backyard exit.. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in the laundry room and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: is currently being used as a lounge/rest area only.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range 112.3°F to 119.0°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the living room cabinet.

Client records: Client records are reviewed. One (1) out of two (2) dementia residents did not have a current medical assessment on file. One (1) out of six (6) residents did not have physician's report on file and one (1) out of six (6) residents did not have pre admission appraisal on file. Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 10/10/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2024 12:54 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TITA GUEST HOUSE	FACILITY NUMBER: 197608161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review the licensee did not comply with the section cited above in one (1) out of six (6) residents did not have pre admission appraisal on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Assistant Administrator agreed to obtain pre admission appraisal t for R1 and submit a copy to CCL on or before the POC date.

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review)], the licensee did not comply with the section cited above in one (1) out of six (6) residents did not have medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Assistant Administrator agreed to obtain a medical assessment for R2 and submit a copy to CCL on or before the POC 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.

Troy Agard	TELEPHONE: (818) 596-4342
Jose Gary Tan	TELEPHONE: (323) 213-1149
	DATE: 12/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2024 12:54 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TITA GUEST HOUSE	FACILITY NUMBER: 197608161
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in one (1) out of two (2) dementia residents did not have current medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Assistant Administrator agreed to obtain a current medical assessment for R1 and submit a copy to CCL on or before the POC date.

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.

Troy Agard	TELEPHONE: (818) 596-4342
Jose Gary Tan	TELEPHONE: (323) 213-1149
	DATE: 12/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2024

LIC809 (FAS) - (06/04)

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