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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610040
Report Date: 03/14/2024
Date Signed: 03/14/2024 08:39:28 PM

Document Has Been Signed on 03/14/2024 08:39 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:MONTARE AT THE CANYON 2FACILITY NUMBER:
197610040
ADMINISTRATOR:ALEXANDRA DECLEENEFACILITY TYPE:
772
ADDRESS:2890 KANAN DUME RDTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY: 10CENSUS: 0DATE:
03/14/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Katarina Boshoff, Vice President of Development TIME COMPLETED:
12:40 PM
NARRATIVE
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At 10:30am, Licensing Program Analysts (LPAs) Angela Panushkina and Leslie Ngo-Castaneda, conducted a Case Management Visit at this facility. LPAs met with Vice President of Development and explained the reason for the visit.

This is in reference to the complaint, control #31-AS-20240129123614. It was discovered during the Non-Compliance Conference (NCC) that the facility had only one (1) staff on duty. Therefore, due to insufficient staffing Client #1 (C1) was able to gain access to the medication room that was left unlocked. Once C1 gained access to the room, C1 was able to ingest medications that resulted C1 to be transferred to ICU at Los Robles Hospital.

Deficiency cited on LIC809-D.

Appeal Rights explained. Exit Interview conducted and copy of this report signed and delivered.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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Document Has Been Signed on 03/14/2024 08:39 PM - It Cannot Be Edited


Created By: Angela Panushkina On 03/14/2024 at 11:12 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONTARE AT THE CANYON 2
FACILITY NUMBER: 197610040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/14/2024
Section Cited
CCR
81078(a)

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81078 Responsibility for Providing Care and Supervision: (a)The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidence by:
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Licensee agreed to submit a statement of explanation regarding this section and provide a copy of LIC500 to reflect the facility has at least two (2) staff member during each shift.
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Based on interviews the licensee did not comply with the section cited above by failing to have enough staff members to provide care and supervision, which poses/posed an immediate health and safety risk to clients 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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