197609683-12-21-2023-31-AS-JGTN-CYR4WR-20231221182821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609683
Report Date: 12/21/2023
Date Signed: 12/21/2023 06:29:20 PM

Document Has Been Signed on 12/21/2023 06:29 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:	LONE STAR BOARD & CARE TUJUNGA		FACILITY NUMBER:	197609683
ADMINISTRATOR:	ALEXANDER, OTIS		FACILITY TYPE:	735
ADDRESS:	10117 TUJUNGA CANYON BLVD		TELEPHONE:	(818) 875-4501
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY: 35		CENSUS: 32	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:09 PM
MET WITH:	Gio Monico - Assistant Administrator		TIME COMPLETED:	06:30 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 Analysts (LPA) Gary Tan conducted an unannounced Required One (1) year visit at this facility today. LPA met with Assistant Administrator Gio Monico and explained the reason for the visit. A tour of the physical plant was conducted at 1:23 PM and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door and all over the facility. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. All the staff were observed to be wearing mask. The facility had an approved Mitigation and Infection Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has multiple screening stations all through out the facility. The facility has sufficient stock of PPE in the storage room. The facility has eighteen (18) shared bedrooms equipped with bathrooms in each room. The facility is fire cleared for thirty five (35) non-ambulatory residents, six (6) of which maybe bedridden in rooms 11-14 & 18. Common areas were inspected. The living room, activity room and dining area were observed to be neat, clean and in proper order, The facility maintains a comfortable temperature at 74°F. There is a carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 12/14/23. The facility is equipped with emergency pull alarm and sprinkler system. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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: LONE STAR BOARD & CARE TUJUNGA	FACILITY NUMBER: 197609683
	VISIT DATE: 12/21/2023

NARRATIVE

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(continued from LIC 809)

Laundry area is located in the basement. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at a range of 110.3°F to 113.1°F. There were enough clean linen available in the closets.

Medications were kept in a locked medication cabinet in the medication room. The medications were observed to be locked and inaccessible to residents. There is complete first aid kit located in the medication room.

Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 12/13/22. A fire inspection by the LAFD was last performed on 12/05/23. Disaster drill was last conducted on 11/1/6/23.

There is no body of water at the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area on the middle patio for the residents.

In addition to the physical plant inspection, residents and staff records were reviewed. LPA reviewed files of five (5) randomly selected residents. Residents files appear to be complete and updated. Five (5) staff files were also reviewed, Staff #1 (S1) did not have TB screening on LIC 503 on file.

Citation issued. Appeal rights explained and given. Exit interview conducted. A copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/21/2023 06:29 PM - It Cannot Be Edited

Created By: Jose Gary Tan On 12/21/2023 at 02:59 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: LONE STAR BOARD & CARE TUJUNGA	FACILITY NUMBER: 197609683
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one (1) ] out of five (5) staff records reviiewed, S1 did not have TB screening on file,] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The Assistant administrator agreed to have S1 have a TB screening and will submit the updated LIC 503 to CCL on or before the POC date.

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:

Jose Gary Tan

LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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