197609990-11-17-2023-31-AS-MAGN-CWYKLL-20231026080007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609990
Report Date: 10/25/2023
Date Signed: 11/17/2023 08:45:44 AM

Document Has Been Signed on 11/17/2023 08:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMENA LOVE BOARD AND CARE		FACILITY NUMBER:	197609990
ADMINISTRATOR:	JONES, MERCER		FACILITY TYPE:	740
ADDRESS:	10751 VIKING AVE		TELEPHONE:	(747) 239-3247
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 4	DATE:	10/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Mercer Jones- Administrator		TIME COMPLETED:	04:15 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 Analysts (LPAs) Mariana Agban and Christopher Alemoh conducted an Annual Required visit and inspection of the facility. LPAs met with staff Carlo Magcalas and explained the reason for the visit. LPAs observed staff #1 (S1) cleaning the kitchen. Shortly after, LPAs met with Administrator Mercer Jones. At approximately 10:10 am, with the assistance of staff, LPAs took a tour of the physical plant, facility temp at 77 degrees. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are properly functional. The fire extinguisher is located in the kitchen with date of purchase 3/3/2023. Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: The facility has five (5) bedrooms total. There were four(4) bedrooms designated for residents' use. One(1) bedroom is designated for staff. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are five (5) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108, 109.102.7.111.3 degrees Fahrenheit. LPAs observed cleaning supplies under the sink cabinet not locked in the main restroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area: is located in the garage which is inaccessible to residents. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. LPA observed that Staff#1 (S1) is not background cleared to work in the facility. Medications: LPAs observed that centrally stored medication records are missing required information. Deficiencies and civil penalty issued. Appeal rights given. Exit interview conducted and copy of this report delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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 11/17/2023 08:45 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMENA LOVE BOARD AND CARE	FACILITY NUMBER: 197609990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

1569.17(b)

This requirement is not met as evidenced by:All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidence by: Based on interviews and review of the personnel file one staff(S1) is not background cleared to the facility.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Administrator will remove S1 immediately and will not allow them to return until they obtain background clearance and assosition to the facility. Administrar will provide a written documentation that S1 not allowed to be in the facility.

Type A

Section Cited

CCR

80087(g)(1)

This requirement is not met as evidenced by: Buildings and Grounds. Storage areas for disinfectants, cleaning solutions, and poisons shall be locked. LPA observed cleaning supplies in a cabinet under the kitchen sink unlocked.
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPA observed multiple cleaning solutions under the restroom sick cabinet which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Assistant administrator moved cleaning supplies to a locked area.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2023 08:45 AM - 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMENA LOVE BOARD AND CARE	FACILITY NUMBER: 197609990
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

This requirement is not met as evidenced by:Health Related Services. Licensees shall maintain, for each client, records of centrally stored prescription medications which shall be retained for at least one year
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above. During Medication Record review, LPA observed missing information in the Centrally Stored Medication and Destruction Recordwhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2023
	Plan of Correction
1 2 3 4	Administrator agreed to go through all medications and make sure all medications are listed on the centrally stored medication log for all clients; and will maintain the information in the clients file.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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