197609817-8-19-2021-31-AS-TCAS-C62VEJ-20210819162225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609817
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:29:53 PM

Document Has Been Signed on 08/19/2021 04:29 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HEALTHY LIFE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197609817
ADMINISTRATOR:	CUICO, FRANCIS-WILLIAM		FACILITY TYPE:	740
ADDRESS:	8627 BOTHWELL RD		TELEPHONE:	(818) 812-9528
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 5	DATE:	08/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Florentino Bunagan		TIME COMPLETED:	04:45 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 Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon arrival, LPA observed a woman on the property sitting in a vehicle, located in the driveway at the facility. LPA was greeted by caregiver Betty Corpus at the front door, who allowed LPA to enter. As LPA entered, there was no routine symptom screening initiated or conducted by the caregiver Betty. LPA was also not requested to sign in the visitor’s book. Caregiver Betty notified the caregiver, Florentino Bunagan, who was also working. Residents were sitting at the dining room table. Everyone was notified the reason of the visit. LPA was informed by caregiver Florentino, the woman sitting outside in the car, was caregiver’s wife, who was waiting for him to get off work. LPA reviewed the personnel summary report and identified the (2) caregivers on duty, during the visit, to be cleared and associated. The wife of the caregiver Florentino was not associated, or fingerprint cleared to be at the facility. A citation and civil penalty will be assessed during today’s visit. The Administrator Francis Cuico was contacted several times by staff and LPA for the reason of the visit. Administrator did not respond for over an hour. Administrator was informed the reason of the visit and made aware of the technical violations and civil penalty citated and assessed during today’s mitigation inspection. There have not been any active or past COVID cases at the facility. There current census is (5), and (3) staff and (5) residents have been vaccinated. LPA observed hand sanitizer by the front door with the visitor sign in book. LPA observed COVID-19 posting on the outside front door. Upon entry inside, there were no signs visibly posted throughout the facility, including inside the front entrance, living room walls, hallway, and other parts of the facility. LPA informed the caregiver, that more signs should be posted throughout the walls inside the facility. LPA did observe COVID signs and handwashing signs in the kitchen and bathroom area. Florentino.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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 13

Document Has Been Signed on 08/19/2021 04:29 PM - It Cannot Be Edited

Created By: Tuesday Cabiness On 08/19/2021 at 03:15 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: HEALTHY LIFE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197609817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

This requirement is not met as evidenced by: During today's infection inspection visit, LPA observed a woman on the property sitting in a vehicle, located in the driveway at the facility. LPA was informed by caregiver Florentino, the woman sitting outside in the car, was caregiver’s wife, who was waiting for him to get off work. LPA reviewed the personnel summary report and identified the (2) caregivers on duty, during the visit, to be cleared and associated. The wife of the caregiver Florentino was not associated, or fingerprint cleared to be at the facility. A citation and civil penalty will be assessed during today’s visit
	Deficient Practice Statement
1 2 3 4	Based on today's infection control visit, LPA observed and identified the caregiver's wife at the property, and was not associated or fingerprint cleared to be at the facility. LPA was informed the wife is waiting for the caregiver Florentino to be off work. This poses as an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2021
	Plan of Correction
1 2 3 4	Begin the process to associate or fingerprint the staff observed during today's visit. The initiation of the document need to be submitted to LPA on or before, Friday, August 20, 2021 by the end of the day, 5pm.

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:

Cassandra Harris

LICENSING EVALUATOR NAME:

Tuesday Cabiness

LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 13 of 13

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: HEALTHY LIFE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197609817
	VISIT DATE: 08/19/2021

NARRATIVE

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The infection control inspection was conducted throughout the facility with the caregiver The facility has (4) shared bedrooms; with (1) room for staff and (2) bathrooms. Beds were kept (6) feet apart. All common areas were observed to be clean, including bathrooms, that had soap and towels. There were hand washing signs observed at the kitchen sink and all bathrooms. LPA conducted a mitigation plan review with the caregiver Florentino, due to Administrator not being available to answer questions pertaining to the mitigation plan that was submitted, reviewed, and approved on January 30, 2021. LPA needed to inquire obtain information, how the facility has implemented the plan. Caregiver Florentino, with limited information, reported they no longer conduct COVID-19 surveillance testing, since everyone has been vaccinated. Daily temperature for residents is performed daily, but the facility does not document or keep record of it. Visitation is conducted outside and in common areas, such as the living room. Residents eat together and practice social distancing at the dining room table. Caregiver could not provide information pertaining to: departmental PINs; training to staff in relation to COVID-19; staff scheduling; notification to residents about infection control policies; procedures in monitoring the spread of the virus; procedures for the hiring process of new staff and resident admit; isolation and quarantine of residents; procedures how to screen, isolate and test residents; a staffing plan to limit transmission; and sick leave policies for staff. There are no designated rooms for potential positive COVID residents. Caregiver Florentino could not provide the procedures or plan if residents test positive for COVID. Facility had sufficient supplies of PPE, chemicals, cleaning supplies, and paper products.

LPA observed the facility has Licensing requirement for food supply; with an extra freezer located in the laundry room. During the visit, the facility had sufficient staff; but LPA does have concerns, due to the number of residents that are non-ambulatory. There is no staffing procedure in place for shortages if needed. The facility has not had any positive COVID-19 reports for staff or residents. Facility was made aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases. LPA is noting that although the Administrator submitted a mitigation plan for review and was approved; during today’s infection inspection visit, the Administrator is not properly and implementing all measures that are required in the mitigation plan. LPA will discuss with LPA the correct plan of action to ensure that the Administrator is implementing the best practices for their facility, staff and residents, pertaining to COVID-19.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 11 of 13

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: HEALTHY LIFE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197609817
	VISIT DATE: 08/19/2021

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	Exit interview, appeal rights, technical assistance (TA) violations, and civil penalty was assessed and emailed to Administrator. LPA discussed report with caregiver Florentino.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

Page: 12 of 13