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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:20:27 AM

Document Has Been Signed on 01/31/2023 11:20 AM - 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:HEPZEBAH HOUSEFACILITY NUMBER:
197609871
ADMINISTRATOR:JACKSON, SYLVIAFACILITY TYPE:
740
ADDRESS:22230 VANOWEN STTELEPHONE:
(310) 213-4927
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 4DATE:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Sylvia JacksonTIME COMPLETED:
11:40 AM
NARRATIVE
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At 11:05 a.m. on 01/31/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator and disclosed the reason for the visit.

At 3:30 p.m. on 12/01/2022, a Non-Compliance Conference was held at the Woodland Hills-South Regional Office to discuss complaint #31-AS-20220210102557 and other facility deficiencies. Attendees included Licensee Sylvia Jackson, Regional Manager (RM) Angela Kendrick, Licensing Program Manager (LPM) Cassandra Harris, and Licensing Program Analyst (LPA) Nicholas Reed. The conference was later changed to an Informal Conference. LPM, LPA, and Licensee discussed the nature of the allegation of neglect. All parties agreed the allegation was not appropriate for the deficient facility practices. Therefore, the allegation was successfully appealed and dismissed. The facility deficiencies are addressed during today’s case management visit.

Resident #1 (R1) was admitted to the facility on 11/14/2020 and was sent to West Hills Hospital on 11/23/2020 after R1 was found unresponsive. During the 12/01/2022 Informal Conference, the Administrator noted the facility should have performed a more complete preadmission appraisal to identify R1’s pressure injuries prior to admission. Additionally, resident files stored at the facility were incomplete. The deficiencies are addressed on the following LIC 809-D page.

Exit interview conducted. Copy of report issued. Appeal Rights discussed.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
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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Document Has Been Signed on 01/31/2023 11:20 AM - It Cannot Be Edited


Created By: Nicholas Reed On 01/31/2023 at 10:52 AM
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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2023
Section Cited
CCR
87457(c)

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87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs
This requirement was not met as evidenced by:
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Licensee will submit a written statement regarding the cited section.
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Based on record review and interviews, the licensee did not comply with the section ctied above in 1 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/03/2023
Section Cited
CCR87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement was not met as evidenced by:
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Licensee will ensure complete and current records are maintained at the facility for all residents in care by the POC due date.
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Based on record review and interviews, the licensee did not comply with the section ctied above in at least 1 resident which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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