197609887-1-24-2022-31-AS-SSTS-CAYS39-20220124123045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609887
Report Date: 01/24/2022
Date Signed: 01/24/2022 12:31:35 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FRANCES MANOR II		FACILITY NUMBER:	197609887
ADMINISTRATOR:	PROVOST, EDNA		FACILITY TYPE:	740
ADDRESS:	25690 YUCCA VALLEY ROAD		TELEPHONE:	(323) 919-9331
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	01/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Edna Provost		TIME COMPLETED:	12:45 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) Shira Stamps, met with administrator Eddie Provost for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:20 am and was greeted by caregiver Cherry Flores. One (1) resident was observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 10:39 am. LPA informed the Administrator of the purpose of the visit. Infection control: LPA reviewed facility mitigation plan (approved on 04/21/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked to answer infection control questions. LPA was asked to sign-in and sanitize hands. A physical plant tour was conducted with Administrator at 10:42 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. The facility is Fire Cleared for six (6) non- ambulatory, one of which may be bedridden. Resident Rooms LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational for each room. Bathrooms At 10:50 am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 10:58 am and measured within regulation at 117.5 degrees F.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

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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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: FRANCES MANOR II	FACILITY NUMBER: 197609887
	VISIT DATE: 01/24/2022

NARRATIVE

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Food Inspection
LPA conducted tour at the kitchen around 10:42 am and observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. Medications and chemical/hazardous items were observed to be locked.

Physical environment
LPA toured the outside area of the facility at 10:49 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. At 10:50am a body of water/spa was observed to be locked.

Living and dining
At 10:42am, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 67°F. The smoke detectors and dual carbon monoxide detectors were tested and observed to be operational at 10:55 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 11/05/21. At approximately 10:42 am, the Resident files and personnel files were observed to be locked in the dining room.

Garage
At 10:48am, LPA observed the garage to be attached to the facility and currently being used for extra food storage and extra hygiene supplies. LPA observed all chemicals/hazardous items locked and inaccessible to residents in care.

Administrative: LPA completed a record review, and the facility has three (3) residents on hospice, with only a hospice wavier for two (2) residents. LPA collected the resident roster and LIC.500. Annual fee is current.

An exit interview was conducted, deficiency cited, and a copy of this report was given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: FRANCES MANOR II	FACILITY NUMBER: 197609887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87632(a)

87632 (a) Hospice Care Wavier In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. 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, and failed to obtain a hospice waiver to accept a third (3) resident on hospice as the facility only has a hospice waiver for two (2) which posses an immediate health and safety risk to residents in care.
	POC Due Date: 01/25/2022
	Plan of Correction
1 2 3 4	The Licensee shall apply for a hospice wavier for three (3) resdients. The Licensee will submit a hospice wavier request to LPA by POC date 01/25/22.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC809 (FAS) - (06/04)

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