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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609544
Report Date: 11/01/2022
Date Signed: 11/01/2022 10:14:57 AM

Document Has Been Signed on 11/01/2022 10:14 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: DATE:
11/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Proserfina Espiritu TIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit due to an incident that happened on 9/14/22. LPA met with facility staff and explained the reason for this visit.
On 9/14/22 there was an incident where a client #1 (C1) was alleged to be hit by staff # 1(S1). Administrator was made aware of incident but failed to report the alleged incident to Community Care Licensing in a timely manner. A serious incident report was not sent to Licensing until 10/11/22. Due to the incident not being reported in a timely manner a deficiency is issued on LIC 809 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2022
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 2
Document Has Been Signed on 11/01/2022 10:14 AM - It Cannot Be Edited


Created By: Wendell Smith On 11/01/2022 at 09:48 AM
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: EPT BETTER LIVING
FACILITY NUMBER: 197609544

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements-Each licensee or applicant shall furnish to the licensing agency reports as required by the Department submitted to the licensing agency within seven days following the occurrence of such event.
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Administrator will submit written statement that all incident reports will be reported in a timely manner by poc due date.
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This requirement was not met as evidenced by:
Based on interviews and documentation obtained an incident happened on 9/14/22 regarding C1 but was not reported until 10/11/22 which posed a potential health and safety risk to clients in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022


LIC809 (FAS) - (06/04)
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