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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609758
Report Date: 04/22/2024
Date Signed: 04/22/2024 04:59:03 PM


Document Has Been Signed on 04/22/2024 04:59 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:DANIAS SENIOR HOMEFACILITY NUMBER:
197609758
ADMINISTRATOR:BAEZA, DANIA ELISABETHFACILITY TYPE:
740
ADDRESS:22331 COVELLO STTELEPHONE:
(747) 226-3342
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY:6CENSUS: 6DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Dania E. Baeza, Administrator DesigneeTIME COMPLETED:
05:25 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
At 12:33 PM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA were greeted by the staff, Elvis Martinez, who granted access to the facility. Later, LPA met with the Administrator designee, Dania E. Baeza, and LPA explained the reason for the visit.

At am, LPA conducted a tour of the facility, and the following was observed:

Kitchen: At 12:50 PM, LPA 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. LPA observed a sharp scissor in the kitchen drawer accessible to residents in care. The Administrator designee immediately locked the scissor with other sharps in the kitchen. There is a fire extinguisher in the kitchen, and it was last purchased on 03/25/2024.



Medications: At 12:52 PM, LPA observed First Aid Kit complete with the required items as per Title 22 Regulations. LPA also observed medications are centrally stored, and locked in the kitchen cabinet; however, review of R1's random medication revealed that the facility was supposed to start Quetiapine Fumarate 50 MG (Depression Medication) new bubble pack on 04/01/2024. During today's visit LPA counted R1's medication and it was discovered that there was a discrepancy and one (1) extra pill was in the pack. LPA asked the Administrator designee for explaining and they could not provide any answers. LPA also observed Centrally Stored Medication (LIC 622) records and did not observe when the medication start date. A deficiency will be cited.


Continue on LIC 809C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758
VISIT DATE: 04/22/2024
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
Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. Facility is licensed for one bedridden resident; however, during the tour that there are three bedridden residents residing in the facility in bedroom # two (2), bedroom # four (4), and bedroom # five (5). All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Staff bedroom is located by the living room and LPA observed staff room to be free of obstruction or hazard.

Bathrooms: At 1:08 PM, LPA 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. LPA observed appropriate grab bar and non-skid mat. LPA 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 1:10 PM, LPA toured the outside area of the facility. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. LPA observed sharp gardening tools accessible and unlocked to residents in care. LPA 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 unlocked and accessible to residents in care with all toxins (laundry detergents).
Continue on LIC 809C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/22/2024 04:59 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, licensee did not comply with the section cited above to make laundry detergents and sharp gardening tools inaccessible to residents in care as the detergents were stored in a unlocked cabinet in the laundry room with the laundry room door open/unlocked and the gardening tools accessible in outside area of the facility which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/22/2024
Plan of Correction
1
2
3
4
Administrator locked the cabinet and the laundry room door and locked away the gardening tools during the visit.

Cleared during visit.
Type A
Section Cited
CCR
87705(f)(1)

(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 observation, the licensee did not comply with the section cited above a sharp scissor was in an unlocked kitchen drawer and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
1
2
3
4
Administrator immediately removed and locked away the scissor. Administrator also agreed to provide training to their staff and provide LPA with a proof by the due date.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 04/22/2024 04:59 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance: (a) All facilities shall maintain a fire clearance approved... Prior to accepting or retaining any of the following types of persons... (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above by accepting three (3) bedridden residents in bedroom # two (2), # four (4), and # five (5) without having a proper fire clearance, which poses an immediate health, safety or personal rights
POC Due Date: 04/23/2024
Plan of Correction
1
2
3
4
Licensee agreed to complete and submit LIC200 along with the facility sketch to Fire Department for a Bedridden and non-ambulatory approval by POC date. Bedridden plan of operation and proof will be submitted to LPA
Immediate Civil Penalty of $500.00 issued
Type A
Section Cited
CCR
87465(c)(2)
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R1's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
1
2
3
4
Administrator agreed to schedule a training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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 GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 04/22/2024 04:59 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)

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:
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. Upon LPA's request staff/Administrator designee was unable to provide any personnel records for any of their staff including the themselves (Administrator designee). LPA was informed that the administrator designee could not locate any of the personnel files. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
1
2
3
4
Administrator designee agreed to have a complete files/records for thier staff in the facility by the due 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758
VISIT DATE: 04/22/2024
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
Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:20 PM, they were tested and observed to be operational.

Between 2:15pm to 3:45pm, LPA reviewed records of six (6) residents and zero (0) staff. Two (2) out of six (6) files were missing identification information, and two (2) out of six (6) resident did not have current physician report on file. Administrator could not provide any staff files to LPA for review.



Administrative: LPA 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 given to Administrator.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6