197610103-1-30-2024-31-AS-ERIS-CZYTDY-20240130133909

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610103
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:39:37 PM

Document Has Been Signed on 01/30/2024 01:39 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	INGOMAR HOME		FACILITY NUMBER:	197610103
ADMINISTRATOR:	SOSKIN, MICHAEL		FACILITY TYPE:	735
ADDRESS:	21007 INGOMAR ST		TELEPHONE:	(323) 854-7740
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY: 4		CENSUS: 4	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Millicent Dimson/ House Manager		TIME COMPLETED:	01:55 PM

NARRATIVE

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On 01/30/2024 at 09:50 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual Visit. LPA met with House Manager, Millicent Dimson who granted access. LPA contacted the Administrator and explained the reason for the visit. Administrator is unable to join LPA at the facility and designated Millicent to sign todays report. This is a one story facility with fire clearance for 2 non-ambulatory and 2 ambulatory clients with a total capacity of 4.

At 10:00 a.m. LPA and the house manager toured the facility inside and out. LPA observed the following:

Common Areas: These include the living room, dining areas. LPA observed two separate dining areas with table and chairs that sits the capacity of the facility. The dining areas and living room were clean and clear of clutter.

Kitchen: LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods; properly stored. LPA observed the knives and sharps locked in a kitchen cabinet. LPA observed one (1) fire extinguisher in the kitchen fully charged.

Bedrooms: There are three (3) client bedrooms, one (1) of which is shared. LPA observed bedrooms to be properly furnished with a bed, linens, night stand, a chair, drawers, closet, and adequate lighting.

Bathroom: There are three (3) bathrooms, one (1) is located in the shared bedroom for private use. The bathrooms contained hand soap, paper towels, toilet paper and hand washing signs. Hot water temperature was taken in two (2) out of three (3) bathrooms at approximately 10:55 a.m. Hot water temperature for bathroom in shared bedroom measured 121.7 degrees Fahrenheit and the bathroom in the hallway measured 122 degrees Fahrenheit.

Laundry Room: LPA observed the laundry room unlocked. Laundry room has a washer and dryer. LPA observed detergents and cleaning products locked in a cabinet on top of the appliances. (Continue on LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INGOMAR HOME	FACILITY NUMBER: 197610103
	VISIT DATE: 01/30/2024

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Garage: The garage is attached to the facility and was unlocked. Garage stores extra emergency and non-emergency supplies for the facility.

Backyard: LPA observed appropriate outdoor furniture for clients. LPA observed an outdoor umbrella that provides shade for clients. The side gate leading from the backyard to the front yard was closed but not locked.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by the house manager at 11:04 a.m. and were observed operational. Smoke detectors are interconnected and one carbon monoxide detector was observed on a wall by the kitchen.

Client Records: At approximately 11:20 p.m. four (4) out four (4) client records were reviewed to insure compliance. One client receives one on one care from Right Choice, a vendorized agency by North Los Angeles County Regional Center (NLACRC).

Medications: At approximately 12:20 p.m. LPA with the house manger reviewed Centrally Stored Medication Destruction Records for proper documentation. Medication records are automatically filled by pharmacists for four (4) out of four (4) clients. Facility also maintains Medical Administration Records (MAR).

Staff Records: At 12:51 p.m. LPA conducted record reviews for three (3) out of (7) staff files to insure compliance with licensing forms.

Deficiency cited on todays visit (Refer to 809-D). Exit interview conducted. Appeal Rights provided. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2024 01:39 PM - It Cannot Be Edited

Created By: Evelin Rios On 01/30/2024 at 01:12 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: INGOMAR HOME	FACILITY NUMBER: 197610103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in two (2) out of three (3) bathrooms hot water temperature for bathroom in shared bedroom measured 121.7 degrees Fahrenheit and the bathroom in the hallway measured 122 degrees Fahrenheit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee will lower water temperature. Licensee shall submit a picture of water temprature on a themometer to LPA with required range of 105-120 degress fahrenheit by poc due date 02/02/2024.

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:

Eva Miller

LICENSING EVALUATOR NAME:

Evelin Rios

LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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