197610099-4-15-2023-31-AS-JGTN-CQWTSM-20230415145922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610099
Report Date: 04/15/2023
Date Signed: 04/15/2023 03:47:49 PM

Document Has Been Signed on 04/15/2023 03:47 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:	WYNGATE VILLA GARDENS		FACILITY NUMBER:	197610099
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	7634 WYNGATE STREET		TELEPHONE:	(818) 352-4270
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY: 68		CENSUS: 63	DATE:	04/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Alma Espinal - Staff		TIME COMPLETED:	03:30 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) Gary Tan conducted an unannounced Required One (1) year at this facility today. LPA initially met with staff Vanessa Rodriguez who called the administrator and explained the reason for the visit. The Administrator stated that former administrator Alma Espinal will come. Licensee Christine Juarez and company arrived 30 minutes later and Alma Espinal arrived an hour later. A tour of the physical plant was conducted at 9:40 AM and the following was noted: The facility consists of five (5) buildings, each house has one main entrance. There are required posters posted at each main door and all over the facility. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. All the staff were observed to be wearing mask. The facility had an approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has multiple screening stations all through out the facility. The facility has sufficient stock of PPE in the storage room. The facility has five (5) buildings with a total of (34) shared bedrooms. Each building has their own bathrooms ranging from one at building #3 up to five (5) on building #2. The facility is fire cleared for forty six (46) ambulatory and twenty two (22) non-ambulatory residents, ten (10) of which maybe bedridden in building #2 only. Approved hospice for ten (10) residents. Common areas were inspected. All buildings has its own living room. Activity room is located on building #4 and dining area is located on building #2. Dining area was observed to be neat, clean and in proper order. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 04/07/23. The facility is equipped with emergency pull alarm and sprinkler system.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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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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: WYNGATE VILLA GARDENS	FACILITY NUMBER: 197610099
	VISIT DATE: 04/15/2023

NARRATIVE

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(continued from LIC 809)

Laundry room is located adjacent to the kitchen and was observed to be locked. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry room inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature at building # 1 measured at 144.1°F, building #3 at 128.4°F and building #4 at 129.5°F. The facility handyman immediately adjusted the water heater and last measure was at a range of 118.5°F to 119.2°F for the above mentioned buildings. There were enough clean linen available in the closets.

Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room.

Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 03/03/23. A fire inspection by the LAFD was last performed on 07/27/22 with validity until 03/31/24, In addition to the physical plant inspection, residents and staff records were reviewed.

There is no body of water at the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area on each building for the residents.

LPAs reviewed files of five (5) randomly selected residents. Residents files appear to be complete and updated. Six (6) staff files were also reviewed, staff files appear to be complete and updated.

Citation issued. Appeal rights explained and given. Exit interview conducted. A copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/15/2023 03:47 PM - It Cannot Be Edited

Created By: Jose Gary Tan On 04/15/2023 at 02:57 PM

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: WYNGATE VILLA GARDENS	FACILITY NUMBER: 197610099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2023
	Plan of Correction
1 2 3 4	Cleared during visit, the facility handyman adjusted the water heater of each building mentioned in the reporty.

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:

Naira Margaryan

LICENSING EVALUATOR NAME:

Jose Gary Tan

LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2023

LIC809 (FAS) - (06/04)

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