197609758-4-24-2023-31-AS-APAA-CR83CD-20230424180743

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609758
Report Date: 04/24/2023
Date Signed: 04/24/2023 06:08:44 PM

Document Has Been Signed on 04/24/2023 06:08 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:	DANIAS SENIOR HOME		FACILITY NUMBER:	197609758
ADMINISTRATOR:	BAEZA, DANIA ELISABETH		FACILITY TYPE:	740
ADDRESS:	22331 COVELLO ST		TELEPHONE:	(747) 226-3342
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 6	DATE:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Daiana Baeza, Administrator.		TIME COMPLETED:	05:00 PM

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At 2:00pm Licensing Program Analysts (LPAs), Angela Panushkina and Mariana Agban conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Josephina Vazquez, who granted access to the facility. Later, LPAs met with the Administrator and LPAs explained the reason for the visit.

At 2:10am, LPAs conducted a tour of the facility and the following was observed:

Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPAs observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 2:15pm LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. There is a fire extinguisher in the kitchen and it was last purchased on 12/12/22.

Medications: At approximately, 2:28pm LPAs observed First Aid Kit complete with the required items as per Title 22 Regulations. LPAs also observed medications are centrally stored, unlocked in a kitchen cabinet and accessible to residents in care. LPAs asked S1 to lock the medication cabinet and S1 immediately complied.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DANIAS SENIOR HOME	FACILITY NUMBER: 197609758
	VISIT DATE: 04/24/2023

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tested and observed to be operational. Staff bedroom is located by the living room.

Bathrooms: At 2:30pm LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 111.5°F. LPAs observed appropriate grab bar and non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 2:45pm LPAs toured the outside area of the facility. LPAs also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents.

The garage: The detached garage is being used for an extra storage and was observed to be locked.

Laundry: Laundry area is located by the kitchen/dining area and was observed to be locked and inaccessible to residents.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 3:50pm they were tested and observed to be operational.

Between 3:00pm to 3:45pm, LPAs reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPAs collected Certificate of Liability Insurance and LIC500.

Citations issued on LIC809-D during this visit. Exit interview conducted, appeal rights explained and copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2023 06:08 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DANIAS SENIOR HOME	FACILITY NUMBER: 197609758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/26/2023 Section Cited	1 2 3 4 5 6 7	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... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to conduct in-house training with Administrator and all staff regarding this regulation. A written statement acknowledging the completion of training shall be submitted to the LPA by POC date
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above by keeping centrally stored medication cabinet unlocked, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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