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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 09/17/2024
Date Signed: 09/17/2024 03:07:50 PM

Document Has Been Signed on 09/17/2024 03:07 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR/
DIRECTOR:		ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 6DATE:
09/17/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:04 PM
MET WITH:Nicole De Las AlasTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss the deficiencies cited at the facility during an annual visit conducted on 08/07/2024. Prior to the meeting, the Licensee was given the opportunity to review the facility file.

Present at today's meeting are the following:
· Nicole De La Alas, Licensee
· Troy Agard, Licensing Program Manager (LPM)
· Melissa Spaeth, Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.

BRIEF HISTORY: Facility has been in operation since licensure on 08/26/2020, for a maximum of six non-ambulatory residents. LPM Agard discussed and expressed concern regarding the potential sale of the facility to an individual without notifying CCL. Also, LPA Spaeth discussed the citations that were issued during an unannounced annual inspection on 8/07/2024.

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 09/17/2024
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The following deficiencies were observed:


- The water temperature was tested in the resident's bathroom and was 126.6 degrees F. The deficiency was cleared during LPA’s visit.

- The two caregivers working at the facility have not received the following training: 1) required eight hours of in-service dementia training, 2) the medication assistance training, and 3) CPR and first aid training. The caregivers also have not completed the health screening including the chest x-ray or an intradermal test. The deficiencies have not been cleared.

During the meeting, the Licensee confirmed they have assumed responsibility of the facility as of today, 9/17/2024. The Licensee stated three previous caregivers are now working at the facility. The Licensee will resume as the Administrator. LPA Spaeth received a copy of a letter which confirms the facility is under the supervision of Nicole De Las Alas.

The Licensee shall submit the following to LPA Spaeth:



· Proof of liability insurance
· An updated LIC 500 - Personnel Report
· Staff member Raquel D'Ambrosio's health screening form completed and signed by a physician
· Malina Sorrano and Reyoldo Sorrano will complete the CPR/First Aid training
· The required residents' documentation will be completed.
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The Licensee was informed the above documentation is due Tuesday 9/24/2024. The Licensee was also informed that Community Care Licensing (CCL) shall continue to monitor the facility with annual facility inspection visits and as often as necessary to ensure the Licensee's compliance with Title 22 Regulations. The Licensee was also informed that further citations and/or non-compliance may result in a Non-Compliance Conference with the Regional Manager.

Exit interview conducted and a copy of today's report was provided to the Licensee.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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