<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609667
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:55:48 PM

Document Has Been Signed on 03/14/2024 03:55 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AAA'S ELDERLY CARE INCFACILITY NUMBER:
197609667
ADMINISTRATOR:REYES, MARICELFACILITY TYPE:
740
ADDRESS:3960 WOBURN CTTELEPHONE:
(661) 350-2232
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 3DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MERICEL REYESTIME COMPLETED:
02:45 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) Melissa Spaeth conducted an unannounced visit and was greeted by the two caregivers. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator arrived at 10:55 am. The staff confirmed there are three residents. The facility is licensed for six (6) non-ambulatory, bedridden residents.

LPA Spaeth and the caregiver toured the facility at 10:10 am until 11:19 am.

Common Areas – The living room and family room contained comfortable seating. A dining room table with chairs are located in the kitchen. The family room contained a television.

Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven day supply of non-perishable foods. The knives and cleaning solutions were securely locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable.

Medication - LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet..

Garage//Washer & Dryer – The laundry room was locked and contained the washer/dryer. The door leading to the garage was locked. The garage contained the laundry detergent and an additional refrigerator.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667
VISIT DATE: 03/14/2024
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
Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Bathrooms: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. The water temperature was recorded to be 134.0 Degrees F.

Hallway Closet - LPA observed the clean linens were located in a cabinet.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 11:15 am and were operable.

LPA Spaeth reviewed the resident and staff files at 11:40 am until 12:30 pm. LPA reviewed the medications at 1:00 pm.



Based upon Title 22 Regulations, the following deficiency is substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/14/2024 03:55 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 03/14/2024 at 12:51 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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)(2)
87303 Maintenance & Operation (e) Water supplies….shall be maintained as follows: (2) Faucets used by residents..shall deliver hot water. Hot water temperature controls shall be maintained …to attain a temperature of not less than 105 degree F …& not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations,, the licensee did not comply with the section cited above. The water temperature was recorded to be 134.0 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
1
2
3
4
During LPA's visit, the water temperature was reduced and was recorded to be 105 degrees F at 12:25 pm.
Type A
Section Cited
CCR
87465(h)(2)
87465 incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored. (2) Centrally stored medicines shall be kept in a safe and locked place…not accessible to persons other than employees …

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Spaeth's observations, the licensee did not comply with the section cited above. LPA observed a resident's medication was not safely locked in the medication cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
1
2
3
4
During LPA's visit, LPA observed the resident's medicaitons were safely locked in a locked cabinet.
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
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/14/2024 03:55 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 03/14/2024 at 01:37 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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
88705(k)
88705 Care of persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egrses devices on exterior doors or perimeter fence gates:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations, the licensee did not comply with the section cited above. LPA obseved the delayed egress alarms had been turned off and were not working which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
1
2
3
4
During LPA's visit, the staff turned on the egress signals to the five exits.
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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4