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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609928
Report Date: 03/14/2022
Date Signed: 03/14/2022 01:30:02 PM


Document Has Been Signed on 03/14/2022 01:30 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:COVELLO TOP NOTCH CARE LLCFACILITY NUMBER:
197609928
ADMINISTRATOR:LOPEZ, DAVIDFACILITY TYPE:
740
ADDRESS:18807 COVELLO STREETTELEPHONE:
(818) 855-9615
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:David LopezTIME COMPLETED:
01:40 PM
NARRATIVE
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At approximately 10:20 AM on 03/14/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA later met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility has a fire clearance for 6 ambulatory residents, of which 6 may be bedridden. The facility has hospice waivers for 4 residents.

The facility was a single-story building with kitchen, dining area, living room, and a garage. The facility had a total of 6 bedrooms and 3 bathrooms. LPA observed one resident watching television and other residents in bed.

Entry: At the front, LPA observed a sign for Oxygen in use and a sign instructing visitors to use the main entrance around back. The main entrance could be accessed through a side gate on the west side of the facility. LPA entered through the front door and was not screened for symptoms of COVID-19.

Screening: Licensee showed LPA the screening station at the back end of the house. The screening station contained a digital thermometer and a visitor log for recording contact tracing information and visitor temperature. LPA suggested an additional column on the visitor log for visitor symptoms. All staff were wearing surgical masks. Signs related to the facility’s infection control practices hung on walls throughout the facility. LPA saw additional PPE accessible to staff near the dining room.

Bedrooms: The facility had 6 bedrooms in total. Bedroom #4 was shared, while the rest were private bedrooms. There was also a staff bedroom. The staff bedroom was safe and free from hazardous items. All resident bedrooms contained nightstands, chairs, lamps, dressers, storage space, and beds with adequate bedding. All rooms with oxygen in use were appropriately labeled.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 03/14/2022 01:30 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: COVELLO TOP NOTCH CARE LLC
FACILITY NUMBER: 197609928

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited

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87470(c) An Infection Control Plan shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.This requirement was not met as evidenced by:
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Based on observations, LPA was not screened for symptoms of COVID-19 upon entry. This posed a potential health and safety risk to residents in care.
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Type B
04/14/2022
Section Cited

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.


This requirement was not met as evidenced by:
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Based on observations, the auditory devices on 4 out of 4 exit doors were turned off. This posed 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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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: COVELLO TOP NOTCH CARE LLC
FACILITY NUMBER: 197609928
VISIT DATE: 03/14/2022
NARRATIVE
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Bathrooms: The facility had 3 bathrooms. Two bathrooms were private to Bedroom #5 and Bedroom #1. One bathroom was shared and was located between Bedroom #3 and Bedroom #2. All bathrooms contained fully stocked liquid soap, paper towels, handwashing instruction signs, trash cans, grab bars around showers, and non-skid surfaces or strips. Toilets did not have grab bars, but the facility provided commodes with grab bars. LPA measured water temperature at approximately 12:30 PM to be 115.1 degrees Fahrenheit, though the water took approximately four minutes to get to appropriate levels.

Kitchen: The facility maintained an adequate supply of perishable and non-perishable food. The kitchen also had a free house telephone available to residents. The refrigerator measured 35 degrees Fahrenheit and the freezer measured -3 degrees Fahrenheit. All sharp objects, cleaning solutions, and medications were locked. The keys for the locks hung in the kitchen. LPA advised Administrator that staff should keep the keys on them at all times and the keys should not be accessible to residents.

Laundry: The facility has two operating laundry machines in the garage. The garage was locked.

Common Areas: All floors, ceilings, walls, and furniture were clean and in good repair. Seating at the dining table and television area was arranged to accommodate social distancing. LPA observed board games near the dining table.

Outside: All outdoor areas were maintained and clean.

Safety: LPA observed a fully charged fire extinguisher in the kitchen which was last serviced on 05/06/2021. LPA tested smoke detectors and carbon monoxide detectors, and all were functioning. The facility had non-skid strips at the main entrance and on a ramp exiting the kitchen. All emergency exit paths were free from obstruction. Auditory devices were not turned on during inspection. LPA advised Administrator to turn on auditory devices when residents with Dementia reside in the facility. LPA also advised Adminsitrator to make Emergency Evacuation routes more visible.

During today's visit, facility was not entirely in compliance with Title 22 Regulations and citations were issued.



Exit interview conducted, citations issued, appeal rights discussed, and copy of the report issued.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3