197609871-1-23-2025-31-AS-HRAI-DD7V8J-20250123151249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:14:30 PM

Document Has Been Signed on 01/23/2025 03:14 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:	HEPZEBAH HOUSE		FACILITY NUMBER:	197609871
ADMINISTRATOR/ DIRECTOR:	JACKSON, SYLVIA		FACILITY TYPE:	740
ADDRESS:	22230 VANOWEN ST		TELEPHONE:	(310) 213-4927
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91303
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Sylvia Jackson, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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At 9:30am, Licensing Program Analyst (LPA) Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the staff. Vanisa Campbell, who granted access to the facility and Administrator Sylvia Jackson was contacted via phone. The Administrator arrived shortly after. LPA explained the reason for the visit.

At 9:45am LPA conducted a tour of the physical plant and observed the following:

Facility is licensed for capacity of six (6) non-ambulatory, of which one (1) may be bedridden (in room #1). Facility also has a hospice waiver for two (2) residents.

Kitchen: At approximately, 9:45 AM 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 observed to be locked in a kitchen drawer. LPA observed that all cleaning supplies and laundry detergents are locked under the kitchen sink. LPA observed a fire extinguisher hanging on the kitchen wall and fully charged and purchased on 01/23/2025. Laundry is located by the kitchen and the washer and dryer were actively running and operational.

Medications: At approximately, 9:50 AM LPA observed medications are centrally stored and locked in a kitchen cabinet. At 12:55 PM, during the medication review for Resident #1 (R1), LPA could not verify the accuracy of the medication administration due to the lack of incomplete Centrally Stored Medication Destruction Form. Administrator informed LPA that the Administrator did not complete the form and was unable to provide a reason.

Continue on LIC 809C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Huma Rahimi	TELEPHONE: (818) 304-2399
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
	VISIT DATE: 01/23/2025

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Bedrooms: LPA observed total of four (4) bedrooms designated for residents use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:00 AM, hot water temperature measured at 113.7°F.

Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have a garage. LPA observed two closets, one by bedroom #4 where the extra linen and towels were stored, and another one by the living room where PPE supplies were stored.

Outside areas: At approximately, 10:10 AM LPA toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents.

Between 11:00am to 12:30pm, LPA reviewed records of five (5) residents and requested for one staff file. LPA was informed that Staff #1 (S1) file is not available for review since the Administrator did not complete a file yet. Resident files were not updated/completed.

During the record review of the resident, LPA observed that Resident #4 (R4) was hospitalized twice. The first incident was on 12/09/2024, and the second incident was on 01/03/2025. LPA was informed that R4 was unresponsive on 12/09/2024 and was taken to the hospital. On 01/03/2025, R4 had a fall and R4’s lib was bleeding and R4 was taken to the hospital where R4 got stiches. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R4. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO) since the Administrator did not know to submit an incident report to the department when such occurrences occur. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Smoke detectors/carbon monoxide. Smoke detectors and carbon monoxide monitors were tested at 12:35 PM, and observed to be functional. Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
	VISIT DATE: 01/23/2025

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Administrative: LPA was not provided with a Certificate of Liability Insurance, LPA collected LIC500.

Deficiencies were cited during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 03:14 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: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident... 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. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Licensee agreed to complete/update five (5) out of five (5) resident files and submit to LPA by the POC due date.

Section Cited

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 Licensee/Administrator was unable to provide S1's facility records. LPA was informed that S1 got hired on 01/15/2024 and no file was completed. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Licensee agreed to have an individual file for each staff member along with the training certificate.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Huma Rahimi	TELEPHONE: (818) 304-2399
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 03:14 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: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in two out of two incidents reports for R4 were not submitted to the department which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	LPA was provided both incident reports during the annual inspection visit. Deficiency cleared during the annual visit. Administrator will have to submit a statement of understanding about the above section and reporting requirements.

Section Cited

Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC by the due date to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Huma Rahimi	TELEPHONE: (818) 304-2399
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 03:14 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: HEPZEBAH HOUSE	FACILITY NUMBER: 197609871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee failed to ensure that the administrator had knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	The Administrator agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the Administrators’ section 87405. The Administrator agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding

Section Cited

Incidental Medical and Dental Care (h)(6) … (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions.., which includes (F) Instructions, if any, regarding control and custody of the medication. 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 to ensure that CSMDR were properly documented for accountability. R1’s medication was not documented properly. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Administrator agreed to schedule vendorized 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

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Huma Rahimi	TELEPHONE: (818) 304-2399
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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