197609500-1-10-2024-31-AS-GSAO-CZCTZK-20240110141024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:10:50 PM

Document Has Been Signed on 01/10/2024 02:10 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DEVONSHIRE ELDERLY CARE		FACILITY NUMBER:	197609500
ADMINISTRATOR:	BANGASH, FARAH		FACILITY TYPE:	740
ADDRESS:	17441 DEVONSHIRE STREET		TELEPHONE:	(310) 955-0674
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	01/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Maria Bangash		TIME COMPLETED:	02:30 PM

NARRATIVE

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On 01/10/24, at 08:50 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met Caregiver, Rafiga Bibi. Maria Bangash the designee administrator was called arrived at 10:15 a.m.

LPA asked for the census, resident, and staff rosters.

Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is a fireplace in the living room area that has a covering. There is smoke detectors all over the house. The smoke detectors are hardwired and interconnected and were tested. There is one carbon monoxide against the wall at the entrance of the facility near the dining room area. They were functional. The facility temperature at 72 degrees Fahrenheit. There is one fire extinguisher that is dated January 2024. There is an extra refrigerator in the dining area. There is an Ombudsman, YES sign, Evacuation Plan, Mitigation Plan and administration certificate against the wall in the dining hall. There is internet and phone access in the dining hall.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets on your left-hand side. The medication is kept in the kitchen area on your right-hand side in one of the cabinets locked and secured inaccessible to residents. The toxins are kept in the kitchen area in one the cabinets locked and secured also inaccessible to residents. The first aid kit is located in one of the bottom cabinets in the kitchen area.

809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE	FACILITY NUMBER: 197609500
	VISIT DATE: 01/10/2024

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Bedrooms: There are eight (8) bedrooms. Four (4) of the bedrooms is single, occupied. One (1) of the bedrooms is shared with a private bathroom. There are three (3) bedrooms upstairs for staff use. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. There are two (2) other bathrooms for resident and staff use. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115-119 degree Fahrenheit.

Outside/Backyard: There is a shed storage outside locked and secured with a washer and dryer. There is no garage. The outside/backyard has furniture for residents with proper seating. The facility has no signal system. There is a SPA that has a covering but no fence, accessible to residents.

Administrative: There is no annual fee that is due right now. The Insurance plan is updated as of 08/24/23-08/2024. At the entrance of the facility there is covid signs and PPE items.

An exit interview was conducted, two different citations were issued-one for staff not having current and/or CPR/Firstaid and one for the SPA/Jacuzzi not having a fenced area, locked inaccessible to the residents.
A copy of this report was given to the administrator with the appeal rights.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/10/2024 02:10 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE	FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the licensee did not comply with the section cited above in two out of three persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will email certification of CPR/Firstaid of all staff currently working at the facility.

Type A

Section Cited

CCR

87705(e)

Care of Persons with Dementia

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. 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 in one out of one objects which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator will take a picture of the removal of the SPA/Jacuzzi from the facility or/and or take a picture of a fence and it being locked and secured inaccessible to the residents.

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 Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC809 (FAS) - (06/04)

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