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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 02/11/2022
Date Signed: 02/11/2022 01:00:59 PM

Document Has Been Signed on 02/11/2022 01:00 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: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:
02/11/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sylvia JacksonTIME COMPLETED:
01:00 PM
NARRATIVE
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At approximately 10:15 AM on 02/11/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced initial complaint investigation. LPA met with Administrator and disclosed the reason for the visit.

Census: 4

During the course of the complaint investigation, LPA found deficiencies. LPA was greeted at the door by an individual without a criminal background clearance.

Administrator was not present at the facility when LPA arrived, and only the individual was present. Both the individual and Administrator stated the individual was supervising residents in care because the Administrator felt ill.

LPA reviewed records for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4).

Resident records of R1, R2, and R3 did not contain Physician Reports or reappraisals within the past 12 months.

LPA conducted exit interview, issued civil penalties, discussed appeal rights, and issued report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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 02/11/2022 01:00 PM - It Cannot Be Edited


Created By: Nicholas Reed On 02/11/2022 at 11:53 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: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2022
Section Cited
CCR
87463(c)

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87463 Reappraisals (c) The licensee shall arrange a meeting with the resident... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first.

This requirement is not met as evidenced by:
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Licensee will conduct reappraisals for R1, R2, and R3 by the POC date and fax to LPA for verification.
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Based on records review, R1, R2, and R3 did not have reappraisails in their facility files.
This poses a potential health and safety risk to residents in care.
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Type B
03/14/2022
Section Cited
CCR87458(a)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.
This requirement is not met as evidence by:
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Licensee will obtain medical assessments for R1, R2, and R3 from residents' primary care physicians by the POC date and fax to LPA for verification.
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Based on records review, R1, R2, and R3 did not have Physician Reports or medical assesments in their facility files. This poses a potential health and safety risk to residents 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: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022


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Document Has Been Signed on 02/11/2022 01:00 PM - It Cannot Be Edited


Created By: Nicholas Reed On 02/11/2022 at 12:19 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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2022
Section Cited
CCR
87355(a)

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87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals... and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.
This requirement is not met as evidence by:
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Licensee will prohibit the individual from the premises. Licensee will ensure associated staff are present before leaving the facility. Licensee will provide a statement of these changes to LPA by the POC date to maintain on record.
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Based on LPA observations and interviews, the individual providing supervision to residents in care did not submit a criminal background clearance to the department. This poses an immediate health and safety risk to residents 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: 02/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022


LIC809 (FAS) - (06/04)
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