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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608902
Report Date: 11/12/2024
Date Signed: 11/12/2024 01:05:24 PM

Document Has Been Signed on 11/12/2024 01:05 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:PARTNERS FOR POTENTIAL,INC.FACILITY NUMBER:
197608902
ADMINISTRATOR/
DIRECTOR:		LISA WILLIAMSENFACILITY TYPE:
775
ADDRESS:25022 HAWKBRYN AVENUETELEPHONE:
(661) 253-4545
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 56CENSUS: 9DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Janice DoleTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced Required 1 Year inspection at the facility today. The LPA met with Program Coordinator Janice Dole, who was explained the reason for today's inspection. The Chief Executive Officer Lisa Williamsen was contacted and informed of the visit.

The facility is a Community based Adult Day Program that assists the Developmentally Disabled clients with life skills, job training, etc. Clients also have an opportunity to participate in activities offered at the facility. The capacity for clients is (56); although most clients are out in the community during the day unless they want to perform an activity at the day program site. During today's visit, there were (9) clients present and (3) staff working. LPA was informed, the census varies from day to day how many clients are on site and how many are in the community.

LPA toured the facility to ensure is in compliance with Title 22 Regulations. The facility has multiple activity rooms, a kitchen, locker space for client use and outdoor space for clients. The smoke alarm and carbon monoxide detector are hardwired, and the fire alarm is connected to the fire department. Facility also has fire sprinklers. Fire extinguishers observed were fully charged and last serviced 11/23/2023. The client bathrooms were observed to be clean and sanitary with grab bars and hygiene supplies. LPA measured the hot water, and observed only (1) bathroom, out of (4), in compliance. Water measured in the kitchen 100.4, bathroom # 2, with (2) faucet handles, measured at 105.8. The other (2) bathrooms, are sensory by touch, and water was measured at 64.4 degrees F, which is not in compliance, according to Title 22 regulations. The facility does not provide any meals or snacks. Staff do not assist clients with medications and medications are not stored on site. First aid supplies on site were reviewed. Licensing required documents for staff were reviewed, but LPA was informed that majority of the records are kept at the Van Nuys location. LPA reviewed training records on the computer. LPA informed the Chief Officer and Program Coordinator, that training records need to be kept at the facility.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PARTNERS FOR POTENTIAL,INC.
FACILITY NUMBER: 197608902
VISIT DATE: 11/12/2024
NARRATIVE
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Five staff files were reviewed for, but not limited to criminal record clearance, health screenings with TB results, current first aid and CPR cards and annual training; all files were complete. Training records were on the computer and reviewed.

Five client files were reviewed for, but not limited to, admission agreements, medical assessments, and appraisals. Files reviewed were complete. There was no documentation of a disaster drill that was conducted.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 01:05 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 11/12/2024 at 12:32 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARTNERS FOR POTENTIAL,INC.
FACILITY NUMBER: 197608902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on physical plant inspection, only (1) bathroom's hot water, out of (4) was in compliance. Hot water measured in bathroom # 2 105.8 degrees F, and the other (3) measured at 64.4 degrees F. The kitchen hot water measured at 100.4 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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2
3
4
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:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/12/2024 01:05 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 11/12/2024 at 12:32 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PARTNERS FOR POTENTIAL,INC.
FACILITY NUMBER: 197608902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82087.5(a)(3)
Delayed Egress Devices
(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility could not provide documentation of the last fire drill that was conducted at the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Program Manager or Chief Executive Officer must provide in writing, and documentation that a fire drill was conducted at the facility. A list of all staff names, date, and time of who participated in the fire drill, must be submitted to LPA by the POC date.
Type B
Section Cited
CCR
82023(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility could not provide documentation of the last diaster drill that was conducted at the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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The Program Manager or Chief Executive Officer must provide in writing, and documentation that a diaster drill was conducted at the facility. A list of all staff names, date, and time of who participated in the drill, must be submitted to LPA by 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.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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