<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608406
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:35:34 PM

Document Has Been Signed on 06/23/2023 03:35 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:E-SOLFACILITY NUMBER:
197608406
ADMINISTRATOR:MICHAEL STEPHENSFACILITY TYPE:
775
ADDRESS:7144 BALBOA AVENUETELEPHONE:
(818) 881-4427
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 49CENSUS: 22DATE:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Haley RhyneTIME COMPLETED:
04:00 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) Ashley Smith arrived unannounced to conduct a required one-year annual inspection. The LPA met with Program Director Haley Rhyne and explained the reason for the visit. At 12:40 p.m., the LPA and Ms. Rhyne toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Activity Space: The facility is a single-story structure with two multi-purpose rooms, two bathrooms, staff offices/lounge area, and a kitchen. The LPA did not observe any obstructions or hazards. Equipment used for activities was in good condition at the time of the visit. Cleaning supplies, chemicals, and sharp objects are kept locked and inaccessible. The facility is currently conducting passive COVID-19 screening for staff and participants.

The facility maintains a comfortable temperature. The fire extinguishers were fully charged and were last serviced 3/30/2023. Smoke detectors and carbon monoxide detectors were inspected on 5/30/2023 and were operational and found to be in compliance with Fire Code Regulations. No bodies of water noted. Fire and earthquake drills are conducted monthly.

Food Service: The LPA toured the kitchen/food service area, which was clean and in good condition. The facility provides snacks to the consumers. Food was properly stored and secured.

Restrooms: Restrooms were clean and trash cans have lids to protect consumers from cross contamination. The hot water temperature was tested at 12:50 p.m. and measured at 116.2 degrees Fahrenheit.

Staff records: File review began at 1:20 p.m. The LPA reviewed five staff files and checked for valid first aid/CPR, medical assessments, the appropriate training, and personnel records. Four out of five files (S1, S2, S3, S4) require a health screening. Two out of five staff (S1, S2) were fingerprint cleared but were not associated to this location. Training hours were verified.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: E-SOL
FACILITY NUMBER: 197608406
VISIT DATE: 06/23/2023
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
26
27
28
29
30
31
32
Consumer records: At 1:55 p.m., the LPA reviewed five consumer files and checked for annual service plans/IPPs, admission agreements, and medical assessments. Five out of five files (C1, C2, C3, C4, C5) require an updated individual program plan (IPP), as the ones on file were over a year old.

Medications: The facility currently does not have consumers that require assistance with the self-administration of medication.

Interviews: From 2:20 p.m. – 2:45 p.m., the LPA interviewed three staff and two consumers. No immediate health or safety concerns noted.

Per the California Code of Regulations, Title 22, the following deficiencies were observed and cited during today's visit. (See 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report was issued. Civil penalties assessed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/23/2023 03:35 PM - It Cannot Be Edited


Created By: Ashley Smith On 06/23/2023 at 03:01 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: E-SOL
FACILITY NUMBER: 197608406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82019(e)(3)
Criminal Record Clearance
(e) Prior to working, residing or volunteering in a licensed day program, all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall do the following: (3) Request the licensee or applicant for a license to request a transfer of a criminal record clearance as specified in Section 82019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff (S1, S2), as they were not associated to this location, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
1
2
3
4
The Program Director agreed to do the following:
1. Ensure the staff are associated to this location prior to returning to work.
Civil penalties assessed in the amount of $500 per person, for a total of $1000.
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
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/23/2023 03:35 PM - It Cannot Be Edited


Created By: Ashley Smith On 06/23/2023 at 03:01 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: E-SOL
FACILITY NUMBER: 197608406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065(g)(1)
Personnel Requirements
(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in four out of five staff files (S1, S2, S3, S4) which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
1
2
3
4
The Program Director agreed to do the following:
1. Submit the completed health screenings for the 4 staff no later than 7/10/2023
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in five out of five consumer files (C1, C2, C3, C4, C5) which poses a potential health and safety risk to persons in care.
POC Due Date: 07/10/2023
Plan of Correction
1
2
3
4
The Program Director agreed to do the following:
1. Submit the most up-to-date IPPs for the 5 consumers no later than 7/10/2023
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:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4