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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610154
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:04:49 PM


Document Has Been Signed on 04/25/2024 03:04 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:A PRECIOUS CARE VILLAFACILITY NUMBER:
197610154
ADMINISTRATOR:DOMINGO, OLIVERFACILITY TYPE:
740
ADDRESS:8413 RHEA AVETELEPHONE:
(818) 626-9343
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Madonna Olila- Assistant AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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In conjunction to the complaint number 31-AS-20230406143049 Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a case management- Deficiencies visit.
During the complaint investigation, it was confirmed that Licensee failed to submit a death report for Resident 1(R1) to CCL. LPAs conducted a file review and didn't observe death report on file.

Deficiencies Cited. Exit Interview Conducted. Report Issued
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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


Document Has Been Signed on 04/25/2024 03:04 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: A PRECIOUS CARE VILLA
FACILITY NUMBER: 197610154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by:
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The Administrator will conduct in service training reviewing the regulation section about reporting requirements. The Administrator will provide all training materials and signatures of all staff that have attended the training by the POC due date. Licensee will also submit the Death Report for R1.
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Based on file document review, the Licensee did not comply with the section cited above. Lincesee didn't submit a death report for R1 since they passed away on or around of June or July 2023. This poses a potential health and safety risk to clients 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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