197609060-3-4-2024-31-AS-ERIS-D332CG-20240304161644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609060
Report Date: 03/04/2024
Date Signed: 03/04/2024 04:16:49 PM

Document Has Been Signed on 03/04/2024 04:16 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TREASURE HERITAGE		FACILITY NUMBER:	197609060
ADMINISTRATOR:	OLOWOSAGBA, SUNDAY		FACILITY TYPE:	740
ADDRESS:	2049 KALLIOPE AVENUE		TELEPHONE:	(661) 941-2258
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	03/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Sunday Olowosagba		TIME COMPLETED:	04:30 PM

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On 03/04/2024 at 1:15 p.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Inspection at the facility mentioned above. LPA was greeted by staff #1 (S1) who granted access. Administrator Sunday Olowosagba met LPA shortly after. LPA explained the reason for the visit. The facility is licensed for 6 non ambulatory residents of which 3 may be bedridden with a total capacity of six (6). Facility has a Hospice wavier for 2. The inspection tool was used to complete the visit.

A physical tour was conducted at approximately 1:40 p.m. along with the administrator and LPA observed the following:

Entrance: LPA observed proper postings by the facility entrance. LPA observed hand sanitizer and masks were available.

Common Areas: These include the dining areas, and living rooms. All common areas were observed well lit, clean and clear of clutter. Furniture appeared clean and in good repair. There is an electric fire place not in use properly secured with a glass screen.

Kitchen: LPA observed the kitchen to be clean and clear of clutter. All appliances were operative. Knives are kept locked in a kitchen drawer inaccessible to residents. Cleaning supplies were observed locked under the kitchen sink. LPA observed there to be sufficient supply of 7-day non-perishable foods and 2-day perishable foods. LPA observed a fire extinguisher with a serviced date of 06/08/2023.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There is appropriate outdoor seating for residents and a large umbrella is used to provide shade.

Bedrooms: There are four (4) bedrooms three (3) are designated for resident use. Residents' bedrooms are shared. All resident rooms are furnished with required lighting, dresser, chair, bed, linens, and closets for storage. LPA observed a hallway closet with extra linens and PPE. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREASURE HERITAGE	FACILITY NUMBER: 197609060
	VISIT DATE: 03/04/2024

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Bathrooms: There are two (2) bathrooms designated for resident use. One (1) bathroom is located in the shared bedroom for private use. All bathrooms were well lit, clean, had grab bars, and trash bins with lids. LPA observed a sufficient supply of hand soup, toilet paper, and paper towels. At approximately 1:48 p.m. hot water temperature in one (1) out of the two (2) bathrooms was measured at 117.1°F.

Laundry Room/Garage: Laundry room is kept locked. LPA observed a washer and dryer that appeared operative. LPA observed detergent and extra water for the facility. Through the laundry room is the door to the garage. The garage door was observed locked.

LPA observed smoke detectors through out the facility, they are interconnected and hard wired. LPA observed a carbon monoxide detector on a wall by the bedrooms. At approximately 1:50 p.m. the administrator tested the smoke alarms and they were observed operational.

Resident file: At approximately 1:51 p.m. LPA conducted a file review of three (3) out of three (3) resident records. LPA reviewed resident records to insure compliance of licensing forms. LPA observed one (1) out of three (3) residents was missing examination for communicable tuberculosis. Administrator requested from Hospice Nurse who was present at the time to provide documentation of TB exam for resident #2 (R2) as soon as possible. Hospice nurse said they would. Resident record review also revealed resident #1 (R1) with hearing impairment documented on physician's report did not have the Telecommunication Device Notification on file.

Staff Files: At approximately 2:49 p.m. LPA also conducted a file review of two (2) staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: At approximately 3:00 p.m. LPA observed, resident medications locked in a kitchen cabinet inaccessible to residents. Facility keeps medical administration records (MAR) for residents.

Deficiencies were observed during todays visit. Exit interview conducted. Copy of this report and appeals provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/04/2024 04:16 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TREASURE HERITAGE	FACILITY NUMBER: 197609060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 one (1) out of three (3) residents in care by not having results of a communicable tuberculosis exam on file for resident #2 (R2) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/15/2024
	Plan of Correction
1 2 3 4	Administrator requested results from Hospice nurse present during visit. Administrator will send a copy on TB examination and results to LPA by POC due 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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