197609667-9-20-2024-31-AS-MSPH-D9AT76-20240920142810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609667
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:29:10 PM

Document Has Been Signed on 09/20/2024 02:29 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 INC		FACILITY NUMBER:	197609667
ADMINISTRATOR:	REYES, MARICEL		FACILITY TYPE:	740
ADDRESS:	3960 WOBURN CT		TELEPHONE:	(661) 350-2232
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 3	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maricel Reyes		TIME COMPLETED:	12:27 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator Maricel Reyes arrived at 9:35 am.. 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 9:15 am until 9:55 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 underneath the kitchen sink and was not locked. LPA observed the caregiver locked the cabinet at 9:17 am.. The fire extinguisher is located in the kitchen and is operable.

Medication - LPA observed the resident medications and PPE supplies were safely locked in a kitchen cabinet. LPA observed an unlocked kitchen cabinet which was not locked and contained a previous residen's medication. LPA observed the Administrator removed the medication and disposed of the medication. LPA observed the first aid kit.

Garage//Washer & Dryer – The laundry room contained the washer/dryer. The door leading to the garage was not locked. Additional cleaning supplies and the laundry detergent were not securely locked. LPA observed the cabinet was locked during the visit. An additional refrigerator is located in the garage and contained additional food items.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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

FACILITY NAME: AAA'S ELDERLY CARE INC	FACILITY NUMBER: 197609667
	VISIT DATE: 09/20/2024

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Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Staff Room: The staff room was not locked. LPA observed over the counter medication in the room. LPA Spaeth observed the medication was removed from the room.

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 105.0 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 9:50 am and were operable.

LPA Spaeth reviewed the resident and staff files at 10:15 am until 10:53 am.. LPA reviewed the medications at 10:50 am until 11:00 am There were no issues with the resident and staff files.

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

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

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/20/2024 02:29 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.ASC, 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 observed cleaning solutions were unlocked underneath the kitchen sink and in the garage. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	During LPA's visit, LPA observed the kitchen cabinet was locked and the garage was locked.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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. A previous resident's medication was stored in an unlocked cabinet and the staff's room was not locked & medicaitons were not locked. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	During LPA's visit, LPA observed the medications were removed.

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: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/20/2024 02:29 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.ASC, 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: 09/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 observed the knives were not locked underneath the kitchen sink. This poses an immediate health, safety or personal rights risk to persons in care. health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	During LPA's visit, the cabinet underneath the kitchen sink was locked.

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	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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