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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608907
Report Date: 10/13/2024
Date Signed: 10/13/2024 12:40:57 PM


Document Has Been Signed on 10/13/2024 12:40 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:COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INCFACILITY NUMBER:
197608907
ADMINISTRATOR:CELIA T. OYIBUFACILITY TYPE:
740
ADDRESS:44161 11TH ST. WTELEPHONE:
(661) 317-7354
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
10/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Celia Oyibu - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Gary Tan, met with Administrator Celia Oyibu for a One (1) Year Required visit for this facility. LPA arrived and was greeted by staff Cyrus Domah and explained the reason for the visit. Ms. Oyibu arrived approximately ten (10) minutes later.

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 Mitigation and Infection 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.

A tour of the physical plant was conducted with the administrator at 9:35 AM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for two (2) non-ambulatory residents, one (1) of which may be bedridden. Hospice waiver for two (2).

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 77°F. The smoke detectors are hardwired and interconnected and observed to be operational. The fire extinguisher is located in the laundry room and was last 08/22/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. (continued to LIC 809-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2024
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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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: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907
VISIT DATE: 10/13/2024
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The garage is converted into an additional dwelling unit (ADU) which a family member/staff is currently living. It is also currently being used as frozen food storage.

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. Fire extinguisher is located at the kitchen and observed to be full and current. Laundry room is located adjacent to the kitchen. Laundry soap, chlorine and other cleaning agents were stored on the cabinet above the washing machine and was observed to be locked and inaccessible to residents.



The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amount of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was observed to be locked and inaccessible to residents. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 118.5°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

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

Client records: Client records were reviewed. Resident #1 has a Dementia diagnosis but no updated LIC 602 on file. Staff records: LPA conducted a complete file review of staff records. Staff #1 (S1) has no LIC 503 on file.

Disaster drill was last conducted on 08/30/24. 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. Copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/13/2024 12:40 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: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above as S1 has no health screening record on file which poses a potential health and safety risk to the residents in care.
POC Due Date: 10/21/2024
Plan of Correction
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The administrator agreed to obtain a health screening for S1 and submit a copy to CCL on or before the POC date.
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
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Based on LPA's record review the licensee did not comply with the section cited above in 1 out of 4 resident records reviewed R1 has dementia diagnosis with no updated medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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The administrator agreed to obtain an updated LIC 602 for R1 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.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2024
LIC809 (FAS) - (06/04)
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