197610147-3-30-2022-31-AS-NRED-CD22MK-20220330173116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610147
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:32:35 PM

Document Has Been Signed on 03/30/2022 05:32 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:	HOME CARE OF WEST HILLS #2 LLC		FACILITY NUMBER:	197610147
ADMINISTRATOR:	CAPATAYAN, GLENN R.		FACILITY TYPE:	740
ADDRESS:	22523 SCHOOLCRAFT STREET		TELEPHONE:	(818) 932-0079
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 4	DATE:	03/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Glenn Capatayan		TIME COMPLETED:	05:40 PM

NARRATIVE

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At 3:20 p.m. on 03/30/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility has an approved fire clearance for 6 non-ambulatory residents, of which 1 may be bedridden in bedroom #2. The facility has hospice waivers for 3 residents. The facility uses surveillance cameras at the front, back, and inside of the facility. A current resident has a small white dog. The facility serves residents with Dementia.

Entry: The facility uses an unlocked, rolling gate to secure the front perimeter. At the front entrance, LPA observed a maintained yard, hand sanitizer, and postings for COVID policies, visitation policies, the most recent Provider Information Notice (PIN), and a “No Smoking – Oxygen in use” sign.

Staff took LPA’s temperature upon entry. Staff recorded name and temperature in a visitor log. Once inside, LPA observed postings for Ombudsman contacts, confidential complaints, resident rights, resident councils, facility license, and administrator certificate.

Bedrooms: The facility has 4 bedrooms. 3 bedrooms are shared. One bedroom is designated for staff. All bedrooms contained a chair, nightstand, dresser or storage, lamp, and beds with adequate bedding. All rooms were clean and in good repair. Bedroom #1 is a staff room. LPA observed the room was locked with bug spray inside. The spray was inaccessible to residents. Bedroom #2 and Bedroom #3 had access outside with a ramp leading to the back yard.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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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Document Has Been Signed on 03/30/2022 05:32 PM - It Cannot Be Edited

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: HOME CARE OF WEST HILLS #2 LLC	FACILITY NUMBER: 197610147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 1 razor in the bathroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Adminsitrator locked up the razor during the visit. Licensee will provide the razor for use when needed. Licensee will provide training on the section cited above and submit proof to LPA by the POC date.

Type B

Section Cited

CCR

87468.1(a)(6)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. 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 1 out of 1 exit gate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee will replace the gate latch on the inside for resident access. Licensee will keep all exit doors unlocked. Licensee will provide an in-service training on the section cited above and submit proof to LPA by the POC date.

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 Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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: HOME CARE OF WEST HILLS #2 LLC	FACILITY NUMBER: 197610147
	VISIT DATE: 03/30/2022

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Bathrooms: The facility has 2 bathrooms. One is designated for residents, and the other is designated for staff. Both bathrooms contained liquid soap, paper towels, handwashing instruction sign, and a trash can with a tight fitting lid. The resident bathroom also contained grab bars by toilet and shower and non-skid flooring in the shower. At approximately 3:40 p.m. LPA observed shaving razors in a drawer in the resident bathroom. Administrator confirmed a resident uses the razors to shave. LPA also observed a hole in the wall above the mirror.

Common Areas: Walls, floors, ceilings, and windows were all clean and in good repair. 4 residents were observed watching television in the living room. LPA observed a resident schedule hung on the wall. LPA observed a linen closet with an adequate supply of clean beddings and towels.

Kitchen: Staff were cooking food in the kitchen during inspection. Medications were locked in a cabinet in the kitchen. Medication was also stored in a lockbox in the refrigerator. Cleaning solutions were locked. The facility had an adequate supply of perishable and non-perishable food.

Safety: 4 out of 4 auditory alarms were on and heard during inspection. A fully charged fire extinguisher was observed in the kitchen. It was last serviced on 08/27/2021. The facility has one fire door by resident bedrooms which was operable during test. At approximately 4:00 p.m. LPA tested smoke and carbon monoxide detector in the main hallway. 4 out of 4 facility smoke detectors were heard functioning. At 3:53 p.m. LPA measured water temperature in the resident bathroom at 133.1 degrees Fahrenheit. Staff retested the water temperature and confirmed the temperature. The handrails to the outdoor ramp were secure.

Outdoor spaces: The back yard was maintained and free from hazards. Exit routes were clear. The exit gate had an outward facing latch. LPA could not open the gate.

During today's visit, the facility is not in compliance with Title 22 regulations. Citations issued on LIC 809-D.

Exit interview conducted. Copy of report, appeal rights, and citations issued.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/30/2022 05:32 PM - It Cannot Be Edited

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: HOME CARE OF WEST HILLS #2 LLC	FACILITY NUMBER: 197610147
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 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 degree C) and not more than 120 degree F (49 degree 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 1 out of 1 bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2022
	Plan of Correction
1 2 3 4	Administrator lowered the water heater gauge during visit. Licensee will show proof of water temperature correction by POC due date. Licensee will create a water temperature log for the following month with daily documentation. Licensee will submit the log by the POC due date.

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

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