197610079-2-3-2021-31-AS-EARO-BXVSR6-20210203130547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610079
Report Date: 11/04/2020
Date Signed: 02/03/2021 01:06:20 PM

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:	CANYON VIEW RESIDENTIAL CARE FACILITY, INC.		FACILITY NUMBER:	197610079
ADMINISTRATOR:	VENTURA, CHERYL M.		FACILITY TYPE:	740
ADDRESS:	26881 CUATRO MILPAS STREET		TELEPHONE:	(562) 881-4998
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	6	CENSUS: 6	DATE:	11/04/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Cheryl Ventura, Maricar Joseph		TIME COMPLETED:	04:45 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 Analyst (LPA) Elizabeth Arambulo conducted an announced PRELICENSING visit to this facility and met with administrator Cheryl Ventura and Licensee Maricar Joseph. The applicant is part of a profit corporation “Canyon View Residential Care Facility INC. The facility is an existing facility with a change of corporation. The fire clearance is approved for six non ambulatory clients. Prelicensing Self-Certification Checklist was not completed or received by LPA Arambulo. The report shall be emailed to applicant and hard copy with signature will be sent back to LPA.

Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s Pre-Licensing Visit was conducted virtually with the use of "FaceTime" with Administrator.

LPA reviewed application documents and took a tour of the facility. The facility is a single story home with 4 bedrooms and 2 bathrooms. The staff do not have any staff quarters on the premises. There are three large common areas for activities, tv and lounging for clients. The backyard has a covered porch area with seating and table for 6 . The garage has a second refrigerator that is stocked with meats and overflow of food. The washer and dryer are in the garage area and a locked cabinet ha all the cleaning supplies and other hazardous materials.

There is one fire extinguisher in the kitchen area and a picture of the tag will be sent to LPA. The first aid kit was checked for items and needed disinfectant and an updated manual. The manual on file was from 2016. The carbon monoxide detector was combined with the smoke detector. When checked the batter had to be replaced cause it was already alarming in red light. Battery was changed during the inspection.

All residents bedrooms were set up and each had the proper furnishings of lights, table, chairs, bed. 2 of the six beds had full bedrails. According to licensee they are both on hospice. The other four beds had half bedrails. LPA requested a copy of physicians orders for bedrails. The extra linen was checked and they had a full supply with heavy blankets for each resident.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Elizabeth Arambulo	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

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 2

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: CANYON VIEW RESIDENTIAL CARE FACILITY, INC.	FACILITY NUMBER: 197610079
	VISIT DATE: 11/04/2020

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
26
27
28
29
30
31
32

The licensee failed to update menu, have a plan of operation on location or properly screen staff and residents for covid. LPA requested for resident physician reports , all six beds had a bedrail. 2 residents had a full bedrail. LPA asked for the physician order for bedrails. a Picture of todays temperature log was requested along with the new temperature log to document resident and staff readings. Licensee states she receives the Provider information notices but was not up to date on recommendations for testing, screening for Covid. The administrator said she receives the PIN but does not read it.

Licensee given a listof items to do and submit to LPA.

A second visit is necessary to see if facility is in compliance.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Elizabeth Arambulo	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2