197609878-10-11-2021-29-AS-SWAR-C7PQBM-20211011120146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609878
Report Date: 10/11/2021
Date Signed: 10/11/2021 12:03:16 PM

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FELLI'S ASSISTED LIVING		FACILITY NUMBER:	197609878
ADMINISTRATOR:	CORPUZ, NOEMI		FACILITY TYPE:	740
ADDRESS:	12322 LULL STREET		TELEPHONE:	(805) 427-6232
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	10/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Noemi Corpuz, Administrator		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 10:00 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Noemi Corpuz and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with administrator Noemi Corpuz at 10:06 a.m. to ensure there are no health and safety hazards. The facility currently has no residents in care.
BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs. Between 10:16 a.m. to 10:20 a.m., hot water temperatures measured between 116.3 and 118.9 degrees Fahrenheit in the common and private bathroom(s).
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 115.3 Fahrenheit at 10:15 a.m.
COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA advised the administrator required postings, such as, CDSS PINs and CDSS PIN summaries are to be posted in the facility once there are residents admitted and the facility is providing care. One fire extinguisher was observed to be fully charged.

Continued on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FELLI'S ASSISTED LIVING	FACILITY NUMBER: 197609878
	VISIT DATE: 10/11/2021

NARRATIVE

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BACKYARD: The backyard currently does not have a covered outdoor area equipped with furniture for resident use. The administrator stated once the facility intakes their first resident, there will be covered outdoor area furnisher provided for resident use. There were no bodies of water noted. The garage is detached to the facility. The garage is currently being used as storage. The LPA conducted a walk through the facility garage to ensure there are no health and safety hazards.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

At 10:34 a.m., Annual Fees were discussed during this visit. Licensee did not pay initial Annual fee due on 08/05/2020 for $495. Late fees accrued on 10/15/2020 for $247. Licensee did not pay annual fees due on 08/04/2021 for $495. Late fees accrued on 10/01/2021 for $247. Licensee's annual fees are past due at this time. The total due including late charges is $1,484. The Administrator was advised of annual fees not being up to date via telephone by Licensing Program Manager (LPM) Jeralyn Pfannenstiel prior to 10/11/2021. Licensee stated she will attempt to make the payment to Sacramento as soon as possible.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FELLI'S ASSISTED LIVING	FACILITY NUMBER: 197609878
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, and facility record review, the licensee did not comply with the section cited above, as the licensee failed to ensure the facility annual fees were paid from 2020 through 2021, and the administrator has the knowledge to conform to the applicable laws, rules and regulations by not paying annual fees, which poses a potential health, safety and personal rights risk to residents in care.
	POC Due Date: 10/18/2021
	Plan of Correction
1 2 3 4	The licensee has agreed to do the following: 1. Pay all facility fees due totaling in $1,484.00, and provide proof of receipt to LPA reflecting up to date annual fees by 10/18/2021.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC809 (FAS) - (06/04)

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