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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609325
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:07:36 PM

Document Has Been Signed on 05/19/2023 03:07 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:INDEPENDENT ENTERPRISE HEALTH CARE INCFACILITY NUMBER:
197609325
ADMINISTRATOR:JIM DURANDOFACILITY TYPE:
740
ADDRESS:36722 ROSE STTELEPHONE:
(661) 917-4380
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 4DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Luis Medina (Caregiver)TIME COMPLETED:
03:15 PM
NARRATIVE
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On 05/19/2023 at 10:05 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the above mentioned facility to conduct an unannounced required annual inspection. LPA met with caregiver Luis Medina who granted access. Luis contacted Administrator James Durando at approximately 10:10 a.m. by phone, James reported he would not be able to meet LPA at the facility. James designated Luis to sign todays report(s). Personnel summary report was verified, and staff was cleared to work in the facility. The total capacity is (6), and the current census is (4). Present at the facility was caregiver Luis and resident #1 (R1). Three (3) residents were at day program. Administrator certificate posted and valid and current until November 01, 2023. Facility has an approved Infection Control plan as of 03/21/2021.

At approximately 10:26 a.m. LPA and Luis conducted a physical plant tour of the inside and outside of the facility and the following was observed.

Kitchen: LPA observed knives, a fully stocked first aid kit and PRN for one of four residents stored in a locked cabinet above the refrigerator. Cleaning supplies were on the counter and Luis explained he was cleaning when LPA arrived. Cleaning chemicals and detergents are kept in a locked laundry space located in a hallway when not in use with the washer and dryer. LPA observed there to be an insufficient amount of 2-day perishable and a 7-day non-perishable food supply in the kitchen for the residents in care. Luis explained most residents are at day program and grocery shopping is done every Monday or when needed. LPA observed expired shredded lettuce in the refrigerator and expired pancake mix, and expired stove top cornbread in the pantry. Luis removed and trashed the expired food immediately and said he would address it with the rest of the staff. Fire extinguisher located by the kitchen was observed to be fully charged, with last service date of 04/10/2023. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting. (LIC809-C continued on to next page)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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 5
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: INDEPENDENT ENTERPRISE HEALTH CARE INC
FACILITY NUMBER: 197609325
VISIT DATE: 05/19/2023
NARRATIVE
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Dining table was clear from clutter and had seating for the four residents. Bedrooms: Facility has (5) bedrooms, one (1) bedroom is shared and is vacant. Resident's bedding and linens were in good repair and bedrooms are appropriately furnished. Bathrooms: There are (2) bathrooms both observed to have toilet paper, hand soap, pull up bars and shower mats. Hot water measured at 110.1 degrees Fahrenheit. Personal hygiene products are available for residents. Surrounding Grounds: There were no visible hazards, or bodies of water and passageways were free from obstruction. Exit side gate was easily accessible. Carbon monoxide detector was tested at 10:42 a.m. and operating properly. Smoke detectors had a green light on indicting they have power. Staff and Resident Interviews: At 11:18 a.m. LPA interviewed R1 and it was revealed they have developed a wound and according to R1 they are not in pain. Medications: At approximately 11:50 a.m. LPA and Luis reviewed medications and Centrally Stored Medication records for four (4) out of four (4) residents. Medications are bubbled wrap and refilled automatically by the pharmacy. Garage: LPA did not have access to the garage. At 12:03 p.m. Luis contacted the Administrator and they explained garage access will not be available today because they are unavailable to return to the facility. Luis did not have a key at the facility to open the garage. LPA interviewed Administrator about R1's wound and Administrator explained R1 has been seen by a doctor and was referred to a podiatrist but at this moment does not have home health agency providing care to the wound. LPA asked Administrator where staff and resident records may be located. Administrator stated records should be in a cabinet in the dining room.

Resident and Staff Records: At 12:05 p.m. LPA and Luis attempted to locate resident and staff files but were unsuccessful. LPA was only able to locate Emergency ID information for three (3) out of four (4) residents. LPA was unable to review facility records.

Deficiencies cited (refer to 809-D). Exit interview conducted and copy of report and appeals provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/19/2023 03:07 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/19/2023 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INDEPENDENT ENTERPRISE HEALTH CARE INC
FACILITY NUMBER: 197609325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555(b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in maintaining an adequate supply of 2-day perishable and 7 day non-perishable food supply on the premises which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2023
Plan of Correction
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Administrator will submit a copy of grocery receipts and pictures of food supply by POC due date.
Type A
Section Cited
CCR
87611(a)
87611 (a)Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618, Oxygen Administration - Gas and Liquid; Section 87619, Intermittent Positive Pressure Breathing (IPPB) Machine; Section 87621, Colostomy/Ileostomy; Section 87626, Contractures; or Section 87631, Healing Wounds; licensees who have, or have had, any of the following within the last two years, shall obtain Department approval...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one (1) out of four (4) residents by not obtaining Department approval for retaining R1 who has a healing wound which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Administrator will submit a written request for a restricted health condition for Resident #1 (R1) that includes but is not limited to: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility by POC due 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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/19/2023 03:07 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/19/2023 at 02:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INDEPENDENT ENTERPRISE HEALTH CARE INC
FACILITY NUMBER: 197609325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87755(a)
87755(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not providing access to the garage. Caregiver present did not have a key to allow the LPA access to the garage during a physical plant tour which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2023
Plan of Correction
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Administrator will ensure that facility staff be able to provide access to entire premise to Any duly authorized officer, employee or agent of the licensing agency when the Licensee or Administrator is not able to be present. Administrator will submit a statement of understanding and a plan for how they will ensure access to any place in the facility by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/19/2023 03:07 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/19/2023 at 02:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INDEPENDENT ENTERPRISE HEALTH CARE INC
FACILITY NUMBER: 197609325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
87412(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one (1) out of one (1) personnel records by not having records available to LPA during unannounced annual visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Licensee will send copies of LIC501, LIC503, First Aid / CPR certificate of staff present during annual inspection to CCL by POC due date.
Type B
Section Cited
CCR
87506(a)
87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in four (4) out four (4) residents by not having resident records readily available to LPA or staff present for unannounced annual inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Administrator will ensure that current resident records are kept readily available to facility staff and licensing agency staff. Administrator review title 22 regulation 87506(a)-(e), and send a written statement that the regulation has been reviewed by POC due 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:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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