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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609544
Report Date: 07/29/2023
Date Signed: 07/29/2023 12:48:23 PM

Document Has Been Signed on 07/29/2023 12:48 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
Lookup Error,
, CA
FACILITY NAME:EPT BETTER LIVINGFACILITY NUMBER:
197609544
ADMINISTRATOR:TABACH, ELENAFACILITY TYPE:
735
ADDRESS:18217 WELBY WAYTELEPHONE:
(818) 457-4199
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
07/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Paul Tabachnikov - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required annual inspection. LPA met with Margie Songcuan/Direct Support Professional (DSP) and Loreto Baguio/Caregiver and explained the purpose of the visit. LPA spoke with the Administrator, Paul Tabachnikov on the phone who stated he will arrive at the facility in 45 minutes. The facility is licensed to care for Developmentally Disabled Adults, ages 18 through 59, (4) ambulatory only. All clients residing at this facility receive case management services provided by North LA Regional Center. At 11:15am, Administrator arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Bathrooms have soap and paper towels. Staff perform hand hygiene practices and are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (4) client bedrooms, one (1) staff bedroom, three (3) full bathrooms, a living room/activity area, office area, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. Facility is a Level 4I. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Bathroom #1 does not have window covering and LPA observed mold and mildew around the bath tub area. Exit doors are free of any obstruction and there are no pools or large bodies of water. Attached garage stores PPE supplies, an extra refrigerator/freezer, and emergency food supplies. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked in a storage room where the laundry was located and inaccessible to clients. There are (2) fire extinguishers observed to be fully charged and purchased on 2/21/2023. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. There are no cameras in the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 112.8 deg F in bathroom #1, 113.1 deg F in bathroom #2 and 112.2 deg F in bathroom #3.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Surety Bond Insurance (CNA Surety) is valid and expires 01/01/2026. Fire Drill was last conducted on 12/15/2022 and Disaster drill was last conducted on 11/15/2022. Administrator scheduled the emergency drills for Mon., 7/31/2023. Outdoor space/backyard was inspected and has a shaded area and sitting area.

*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2023
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
Lookup Error,
, CA
FACILITY NAME: EPT BETTER LIVING
FACILITY NUMBER: 197609544
VISIT DATE: 07/29/2023
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Staffing: A total of five (5) staff members plus the Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for two (2) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate expired on 6/05/2023. LPA observed prrof of renewal submitted on 5/29/2023 and received by CDSS on 6/01/2023. Administrator has a valid HIV/AIDS training but cannot access proof at the time of visit. LPA conducted (2) staff interviews.

Client Rights-Information: Client personal rights are posted. Facility provides internet services to all clients and have access to the facility phone. All four (4) clients have personal cell phones and three (3) out of four (4) clients have computers/laptop. LPA conducted (3) client interviews.

Client Records-Incident Reports: LPA reviewed Client files for C1 through C2. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Functional Assessment, Needs & Services Plan, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator (clean and well maintained). There are no clients with special diets residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas and kept in locked storage room outside. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for C1-C4 to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and stored in plastic bags.

Incidental Medical Services: According to the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted, and a copy of this report was provided to Paul Tabachnikov, Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/29/2023 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/29/2023 at 12:24 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
,
, CA

FACILITY NAME: EPT BETTER LIVING
FACILITY NUMBER: 197609544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in that bathroom #1 did not have full window covering and LPA observed mold and mildew around the bathtub area which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator has contacted the handyman to fix the mold/mildew problem and agreed to purchase a window convering. Administrator will submit photos as proof to CCL/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/29/2023 12:48 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/29/2023 at 12:25 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
,
, CA

FACILITY NAME: EPT BETTER LIVING
FACILITY NUMBER: 197609544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80023(d)(2)
80023 Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.
(2) The drills shall be documented and the documentation maintained in the facility for at least one year.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not comply with the section cited above in which LPA observed that the last fire drill conducted by the home was on 12/15/2022 and disaster drill was last conducted on 11/15/2022 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 08/04/2023
Plan of Correction
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The Administrator agreed to conduct the fire & disaster drill on Mon., 7/31/2023 and understood that the home should conduct the drills every 6 months, as required. Administrator will submit the proof of training completion to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2023


LIC809 (FAS) - (06/04)
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