197609118-11-30-2023-31-AS-TSMH-CY42D8-20231130161755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609118
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:18:08 PM

Document Has Been Signed on 11/30/2023 04:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CAPLAND SENIOR LIVING		FACILITY NUMBER:	197609118
ADMINISTRATOR:	MANABAT II, EMMANUEL A		FACILITY TYPE:	740
ADDRESS:	39927 CAPLAND DRIVE		TELEPHONE:	(661) 480-0082
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 4	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Janet Dela Torre		TIME COMPLETED:	04:23 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), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 10:03 am LPA was greeted by staff and disclosed the purpose of the visit. Staff contacted the administrator. LPA conducted a tour of the physical plant at approximately 10:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the living room, dining and family room combination, and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. However, the meat was not properly stored in containers. Resident medications and first aid kit/supplies are stored in hall closet near laundry room. Medications observed to be locked and inaccessible to residents in care. Sharps are locked in kitchen drawer and observed to be in accessible to residents. Toxins are stored and locked in laundry room. Toxins observed to be inaccessible to residents. There is one (1) fire extinguisher attached to wall in kitchen and observed to be charged. Laundry room is located near garage. The appliances observed to be clean and functional.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAPLAND SENIOR LIVING	FACILITY NUMBER: 197609118
	VISIT DATE: 11/30/2023

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
26
27
28
29
30
31
32

(Cont. from 809)

The facility has a total six (6) bedrooms and (3) bathrooms. There is one (1) room for staff room.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall cabinets. Bedroom #5 had one (1) bed with a brace attached to prevent falls.

Each bathroom has the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 115.1, 115.9 and 117.3 -degrees Fahrenheit.

Backyard has the following: Covered patio with tables and chairs. Patio furniture observed to be in good repair.

Attached Garage: Used for PPEs, toxins, and storage.

Shed: Locked shed used to store equipment

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 11:20 am LPA Smith discuss with Administrator over phone the availability of facility staff records. Administrator reveals he has staff records and currently updating them. At 1:50 pm: LPA reviewed three (3) resident files. Three (3) resident files reviewed included medical assessments and appraisals.

Deficiencies noted on 809D

Exit Interview Conducted /Copy of the Report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/30/2023 04:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAPLAND SENIOR LIVING	FACILITY NUMBER: 197609118
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(1)

Postural supports should be limited to devices such as braces[...] position rather than restrict movement iincluding, but not limited to preventing a resident from falling out of bed This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation) ( the licensee did not comply with the section cited above due to brace mounted to bed] [which poses an immedate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/01/2023
	Plan of Correction
1 2 3 4	The administrator/Licensee will provide LPA with correction plan by 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/30/2023 04:18 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CAPLAND SENIOR LIVING	FACILITY NUMBER: 197609118
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(23)

All reaidly perishable foods [...]capable of supporting rapid and progressive growth of micro-organisms which can cause food infections [..] shall be stored in covered containers at appropriate temperatures This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will obtain proper storage containers for storing meat products.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4