197608905-10-22-2023-31-AS-JGTN-CWURMX-20231022130928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608905
Report Date: 10/22/2023
Date Signed: 10/22/2023 01:11:31 PM

Document Has Been Signed on 10/22/2023 01:11 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:	MY HOME II		FACILITY NUMBER:	197608905
ADMINISTRATOR:	MARK YULE		FACILITY TYPE:	740
ADDRESS:	6753 ESTEPA DRIVE		TELEPHONE:	(661) 219-4906
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	6	CENSUS: 4	DATE:	10/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Mark Yule - Administrator		TIME COMPLETED:	01:15 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, initially met with staff Josephine Pataueg for a One (1) Year Required visit for this facility. Staff called the administrator Mark Yule who arrived 30 minutes later. LPA explained the reason for the visit. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. 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 side yard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 9:30 AM. The facility is a single storey building with six (6) residents' bedrooms and two (2) bathrooms currently occupying four (4) residents. There is an additional room and bathroom designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for one (1) resident. 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 dining The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were filled and current.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

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: MY HOME II	FACILITY NUMBER: 197608905
	VISIT DATE: 10/22/2023

NARRATIVE

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The side yard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. The swimming pool is appropriately fenced and was observed to be locked during visit. There is no garage at the facility only driveway at the front. There is a shed at the side yard being used as a storage for old equipment and other supplies. The laundry area is located inside the staff bathroom and observed to be locked and inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in the cabinet under the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

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 of 111.3°F to 116.2°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aid kit has complete tools and supplies.

Client records: Client records are reviewed. Resident #1 (R1) has a Dementia diagnosis but Medical assessment is not current. Staff records: LPA conducted a complete file review of staff record. Staff present did not have current first aid and health screening on file.
Disaster drill was last conducted on 09/19/2023. Required posting are observed to be complete and current and displayed properly at the facility.

Citation issued. Appeal rights discussed and given. 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: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/22/2023 01:11 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: MY HOME II	FACILITY NUMBER: 197608905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 2 staff records reviewed did not have current first aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	The administrator agreed to have the staff to take the first aid training and submit a copy of the certificate to CCL on or before the POC date

Type B

Section Cited

CCR

87412(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 2 staff record reviewed both or them did not have a Health Screening on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	The administrator agreed to have the staff obtain a health screening clearance and submit a copy of the c 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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/22/2023 01:11 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: MY HOME II	FACILITY NUMBER: 197608905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)(A)

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 record review, the licensee did not comply with the section cited above in 1 out of 4 resident record reviewed did not have a current medical assessment and had a dementia diagnosis, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	The administrator agreed to obtain a current medical assessment for R1 and submit a copy of the assessment 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.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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