197609097-6-23-2023-29-AS-CYEE-CT3KKQ-20230623075840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609097
Report Date: 06/15/2023
Date Signed: 06/23/2023 07:59:38 AM

Document Has Been Signed on 06/23/2023 07:59 AM - 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	THREE C'S CARE HOME		FACILITY NUMBER:	197609097
ADMINISTRATOR:	LOPEZ, MILAGROS		FACILITY TYPE:	740
ADDRESS:	6447 BABCOCK AVENUE		TELEPHONE:	(818) 747-2212
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 5	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Milagros Lopez, Administrator		TIME COMPLETED:	05:15 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) Christine Yee conducted an unannounced required Annual Inspection and met with Milagros Lopez, Administrator. LPA Yee explained the reason for today's visit. The inspection was conducted using the CARE tool. The facility is a single storey home consisting of a living room, dining room, kitchen, three bedrooms, a private bathroom, a common bathroom and a detached garage. The facility is fire cleared for five(5) non-ambulatory and one(1) bedridden. The following was observed on today's visit: the living room had the appropriate furniture the dining room was observed with a glass table and four chairs. staff and client files are stored in a cabinet in the living room the kitchen has a stove, refrigerator and dishwasher that were operational toxins and cleaning solutions are stored in a locked in a cabinet under the sink medications are centrally stored in a locked kitchen cabinet sharp knives are stored in a locked kitchen drawer washing machine and dryer are housed in a kitchen closet Perishables for 2 days and non-perishable foods for 7 days were observed

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: THREE C'S CARE HOME	FACILITY NUMBER: 197609097
	VISIT DATE: 06/15/2023

NARRATIVE

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water tested in the common bathroom read 110.9 degrees Fahrenheit
bedroom #1 has 2 twin beds, 2 night stands, 2 chair, 2 lamps and no dressers
bedroom #2 has 1 twin bed, 1 hospital bed with half bed rails, 2 chairs, 2 lamps and no dressers
bedroom #3 has 2 twin beds, 2 night stands, 2 chairs and a two drawer dresser.
the water tested in the private bathroom located in bedroom #3 read 108.9 degrees Fahrenheit.
grab bars, non-skid mats and shower chairs were observed in both bathrooms.
residents beds were observed with a fitted sheet and a blanket. Per the Administrator, the residents choose not to have the other beddings. Plenty of bed linens and towels were observed in a cabinet in the common bathroom. No mattress pads were observed
the interconnected and hardwired smoke detectors were tested at 2:28pm and were operational.
the disposable fire extinguisher located in the kitchen was purchased on 1/24/23
the facility has 2 carbon monoxide detectors - the smoke detector located in front of bedroom #1 is combined with a carbon monoxide detector and the second in in the living room. Both were tested and were operational
The backyard has a table with 4 chairs and an umbrella. The front yard has a table and 4 chairs
The front yard and backyard need general cleaning. Items such as mops, buckets, planters, pile of petrified wood, 2 shopping carts, garden hoses, unused trash cans, clothes rack, shower tools need to be put away or discarded. Overgrown weeds/grass

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: THREE C'S CARE HOME	FACILITY NUMBER: 197609097
	VISIT DATE: 06/15/2023

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need to be removed and the tables covered with bird feces and concrete floor covered with fallen fruits need to be rinsed off.
Files were reviewed and noted on the inspection tool

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not addressed on today's visit will be addressed on a return visit.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/23/2023 07:59 AM - 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: THREE C'S CARE HOME	FACILITY NUMBER: 197609097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(3)(E)

87307 Personal Accommodations and Services: Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. This requirement is not met as evidenced by: Per tour of the 3 residents bedrooms, dressers were not observed in bedroom #1, bedroom #2 and only one dresser was observed bedroom #3
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 bedrooms toured which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Per discussion with the Administrator, dressers will be purchased for all three bedrooms. Photographic evidence and receipt will be provided by the POC date of 6/29/23

Type B

Section Cited

CCR

87307(3)(C)

87307 Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: None of the residents beds were observed with mattress pads and none were observed in the linen closet
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not comply with the section cited above in 5 out of 5 count which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Per discussion with the Administrator, mattress pads will be purchased for the residents and in quantities to allow for changing weekly or as frequently as needed. Administrator will provide evidence of corrections via photograph and a copy of the receipt by POC date of 6/29/23

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 07:59 AM - 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: THREE C'S CARE HOME	FACILITY NUMBER: 197609097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors This requirement is not met as evidenced by: The front yard and backyard were observed with an unrolled hose (rolled during visit) tables with bird feces, mops, buckets, petrified wood, clothes rack, 2 shopping carts, plastic bin, planters, broken trash cans, tall weeds/grass and concrete floor covered with fruits fallen off the tree.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Per discussion with the Admiinistrator, a family member is scheduled to clean the yard this coming weekend - 6/17-6/18/23. Administrator will provide proof of correction by 6/29/23

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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