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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609683
Report Date: 03/15/2022
Date Signed: 03/15/2022 04:04:04 PM

Document Has Been Signed on 03/15/2022 04:04 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LONE STAR BOARD & CARE TUJUNGAFACILITY NUMBER:
197609683
ADMINISTRATOR:ALEXANDER, OTISFACILITY TYPE:
735
ADDRESS:10117 TUJUNGA CANYON BLVDTELEPHONE:
(818) 875-4501
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 35CENSUS: 32DATE:
03/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gio MonicoTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management in conjunction with the complaint investigation to address issues related to the complaint (control #: 31-AS-20220307113017). During the investigation, it was revealed to LPA that the facility did not submit (4) incident reports relating to client # 1 (C1), who was issued an eviction notice for various incidents at the facility. According to staff, there was no explanation as to why the incident reports were not submitted to Licensing.

Also during today's visit, while reviewing C1's file, it was observed that the facility did not have complete Licensing documents, such as a mental health assessment. According to the case management, conducted on 04/24/2021 by LPA Y. Atevisyan, during client file review, the facility also did not have mental health assessments in client files, and reported to LPA Avetisyan, that going forward, the facility would ensure all client's had proper Licensing documentation in there file, such as, the mental health assessment. LPA observed that C1 did not have the documentation in C1's file, therefore, another citation will be issued, as well as a $500 civil penalty, for 2nd a second violation in year, dating from 04/24/2021. These are potential health and safety risks to residents in care.

Also note, the citation issued on the case management conducted by LPA Y. Atevisyan, on 04/24/2021, for Title 22 Regulation: 80075(4)(5)(6), will be re-cited and issued at another date and time, based on documents received and reviewed for plan of correction. It was determined the facility/Administrator did not comply, by not obtaining PRN authorization letter for the client involved in that case management, nor did they submit proper/complete plan of correction documentation. Licensee/Administrator will review all client records to ensure that a PRN authorization letter signed by a physician is on file for all clients.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
VISIT DATE: 03/15/2022
NARRATIVE
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After the review Licensee will submit a written statement with names of clients who do not have PRN authorization letters on files with a written statement that licensee/administrator will ensure to obtain the required document. This poses a potential health, safety or personal rights risk to persons in care. Citation will be issued during another visit.

During today's visit, LPA T. Cabiness will issue citation for failure to report, and not having mental health assessment in C1's file.


Exit interview, citation, appeal, civil penalty issued, and appeal right. Copy of report was issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2022 04:04 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 03/15/2022 at 03:09 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: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited
CCR
85069.3(a)

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Mental health assessment: (a)In order to determine his/her ability to provide the services needed by a client with mental illness...a written intake assessment is prepared as required by Health and Safety Code...
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The Administrator or Case Manager will submit a mental health assessment for client # 1(C1) and ensure it is kept in the file for the remaining (3) years, according to Licensing. LPA is requesting a
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This poses as a potential health and safety risk to clients in care. This requirement was not met, evidenced by, based on record review, C1 was missing a mental health assessment in client file.
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completed copy by the POC date.
Type B
03/15/2022
Section Cited
CCR80061(b)

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Reporting Requirements:(b)Upon the occurrence...(1) below, a report shall be made to the licensing agency within the agency's next working day...a written report...specified...
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Plan of correction cleared. LPA received copies of the incident reports during today's visit
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shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement was not met, evidenced by, during today's visit, facility did not submit several incident reports pertaining to C1.
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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:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022


LIC809 (FAS) - (06/04)
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