197608663-8-13-2024-31-AS-TCAS-D84RTZ-20240813131911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608663
Report Date: 08/13/2024
Date Signed: 08/13/2024 01:22:47 PM

Document Has Been Signed on 08/13/2024 01:22 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:	CEDARCREEK MANOR		FACILITY NUMBER:	197608663
ADMINISTRATOR:	RICHARD K. GORDON		FACILITY TYPE:	740
ADDRESS:	27126 LANGSIDE AVENUE		TELEPHONE:	(818) 269-2230
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91351
CAPACITY:	6	CENSUS: 4	DATE:	08/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Elsie Gomez & Richard Gordon		TIME COMPLETED:	01:30 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) Tuesday Cabiness arrived at the facility to conduct an annual inspection. LPA was greeted by staff Ernesto Guillera, who allowed LPA to enter. The Administrator Richard Gordon was contacted; LPA informed him the reason of the visit, and he arrived to the facility during the visit. Elsie Gomez, the house manager, was not present during the initial visit, but was contacted by the Administrator, and she arrived shortly after. A complete inspection/tour of the facility was conducted from the inside and outside. The following was observed during the inspection: Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer stocked with food, in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, and medication were stored in the kitchen and garage area which was locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (6) bedrooms; with (1) room for staff. The current census is (4). All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 111.4 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. The facility has outdoor furniture, with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. All exit doors have alarms; all were operating. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 08/13/2024 01:22 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: CEDARCREEK MANOR	FACILITY NUMBER: 197608663
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, during today's visit, LPA observed resident # 1(R1) did not have a physician report on. This is a potential health and a safety risk for residents in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87458(a)

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 record review, during today's visit, LPA observed resident # 1(R1) did not have a physician report on file. This is a potential health and a safety risk for residents in care.
	POC Due Date: 09/03/2024
	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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CEDARCREEK MANOR	FACILITY NUMBER: 197608663
	VISIT DATE: 08/13/2024

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Record review: A complete record review of staff and residents were conducted. Resident # 1 (R1) was missing a current appraisal needs/service plan, and there was no physician report in the file. LPA reviewed (R2's) records, and all documents were observed in file.

Staff record review: All records observed in file.

Citations and Technical Violations issued; appeal rights, exit interview, and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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