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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610101
Report Date: 02/03/2022
Date Signed: 02/03/2022 03:03:25 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:HAMLIN ELDER CAREFACILITY NUMBER:
197610101
ADMINISTRATOR:BIGORNIA, LIMA ROSEFACILITY TYPE:
740
ADDRESS:20300 HAMLIN ST.TELEPHONE:
(818) 912-6289
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 4DATE:
02/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH: Lima Rose BigorniaTIME COMPLETED:
03:00 PM
NARRATIVE
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LPA Spaeth conducted an unannounced visit to the facility regarding Complaint 31-AS-20220201103420. During LPA's tour of the facility with the Administrator, LPA observed at 12:15 pm laundry detergent and construction tools including a screw driver and nails were unlocked and located above the washing machine. LPA instructed Administrator that the laundry detergent and tools must be locked in a safe place.

While touring the rooms with Administrator, LPA observed R2's room which contained two beds. R2 was watching television in the living room and a caregiver (S1) was laying on the vacant bed in R2's room. LPA observed the caregiver had previously been working in the kitchen when LPA arrived to the facility. LPA advised Administrator that caregivers are not allowed to sleep in a resident's room.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issued to the Caregiver
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
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: HAMLIN ELDER CARE
FACILITY NUMBER: 197610101
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2022
Section Cited

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87307(a) Personal Accommodations and Services. A facility’s buildings and grounds shall have no other purpose than those related to the care, comfort and privacy of the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
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Based on LPA observations, LPA observed a staff member resting in a resident’s room. Therefore, the staff members was allowed to rest in a resident’s room. This poses a potential health and safety hazard to residents in care.
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Type B
02/03/2022
Section Cited

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87705 Care of persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, …tools and other items that could constitute a danger to the resident(s). (2) Over the counter medications, …and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by: Based on LPA observations, LPA observed constructions tools, nails and a screw driver and laundry detergent were not locked in a safe location. This poses a potential health and safety hazard to residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
LIC809 (FAS) - (06/04)
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