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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609931
Report Date: 01/02/2024
Date Signed: 01/02/2024 01:30:59 PM


Document Has Been Signed on 01/02/2024 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:KAREN'S BOARD AND CARE, INCFACILITY NUMBER:
197609931
ADMINISTRATOR:ZINKOFSKY, CLARITAFACILITY TYPE:
740
ADDRESS:17231 TUBA STREETTELEPHONE:
(818) 216-3271
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 5DATE:
01/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Brandon ZinkofslayTIME COMPLETED:
01:50 PM
NARRATIVE
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On 01/02/24, at 10:20 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA was met by Jim Estabaya. One of the administrators was called and Brandon Zinkofslay-Administrator arrived at 11:05 am.

LPA asked for the census, resident, and staff rosters. At the entrance of the facility there is a sign for Resident Bill of Rights. There is also a staff, storage closet locked and inaccessible to residents.

The physical tour started at 11:30 am. There is no garage but there is a carport area. There is also a shed in the backyard locked where there is extra wheelchairs and beds for residents. There is an extra refrigerator outside with extra food.

Backyard: There is a table set and chairs for residents use. There is enough seating for five (5) residents. There is a pool that is fenced and gated inaccessible to the residents.

Medications and sharps are in a cabinet locked and secured in the kitchen area. It is inaccessible to residents. The first aid is also located in this cabinet.



Kitchen area was observed to be clean. The refrigerator is fully stacked for five (5) residents. LPA reviewed the food service area, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. There is an excess of perishables in several of the cabinets. The disaster plan is located against the wall in a frame on your right hand side of the kitchen area. In addition, there is the YES sign, Rights of Residents and Ombudsman signs. There is a fire extinguisher located in the kitchen against the wall, dated April 2023 and fully charged.

LIC 809C-continued
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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: KAREN'S BOARD AND CARE, INC
FACILITY NUMBER: 197609931
VISIT DATE: 01/02/2024
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Living and dining room furniture is accessible for five (5) residents. There is a television and enough seating for five (5) residents. There is internet accessibility a phone line available for resident use. Furniture was observed to be in good condition and the fireplace has a covering around it.

There is a laundry area with one washer and dryer. The toxins are kept on the side and on top of the laundry area locked and secured inaccessible to he residents.

There is smoke detectors and carbon monoxide detectors that are functional throughout the house.



Bedrooms: There is seven (7) bedrooms. Six (6) bedrooms are single, occupied for residents, One (1) bedroom is for staff use. There is three bathrooms. One and a half bathroom use for staff and residents and one private bathroom. The bathrooms read a temperature between 110.5 and 111.5 Fahrenheit. All bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There are several extra closets in the hallway with extra linen.

Temperature of facility wall thermostat is observed and set to 73 degrees Fahrenheit.



Administrative: There is an annual fee due of $495.00 as of 12/23/2023. The administrator showed proof of insurance plan.

An exit interview was conducted, two different citations were issued-one for staff not having current and/or CPR/Firstaid and one for not having over-night staff for dementia residents, and a copy of this report was given to the administrator with the appeal rights.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/02/2024 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: KAREN'S BOARD AND CARE, INC
FACILITY NUMBER: 197609931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview of two of the administrators and record review, the licensee did not comply with the section cited above in five out of five persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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Licensee/Administrator will email certification of CPR/Firstaid of all five (5) staff currently working at the facility.
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview of one of the administrators and record review, the licensee did not comply with the section cited above in three out of five persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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Licensee/Administrator has to email a staff roster showing who is working the over-night shift caring for the demetia residents.
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: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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