<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610154
Report Date: 05/20/2024
Date Signed: 05/21/2024 09:27:47 AM


Document Has Been Signed on 05/21/2024 09:27 AM - 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: DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Madonna Olila- Administrator TIME COMPLETED:
05:00 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) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Madonna Olila and explained the reason for the visit.
At approximately 10:15 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Smoke alarm/carbon monoxide system is hard wired and operating. The fire extinguisher is located in the kitchen. The purchase date August 13,2023.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.
Bedrooms: The facility has (5) bedrooms, with (1) room for staff; (2) private rooms, and (2) shared rooms. . All four (4) bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 106.5 and 107.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit.
Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area: is located in the garage, which is inaccessible to residents. Medications: Medication and Medication Records were review for proper documentation. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records and observed many licensing forms are missing and or incomplete. Exit interview conducted, Citation Issued, Appeal Right given and copy of this report delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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 5


Document Has Been Signed on 05/21/2024 09:27 AM - 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: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above. Based on records review LPA observed 2 out of 2 staff don't have a fingerprint clearance. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2024
Plan of Correction
1
2
3
4
Administrator will submit a proof of finger print clearance for 2 out of 2 staff.
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above.
POC Due Date: 05/21/2024
Plan of Correction
1
2
3
4
Administrator will submit documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).
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: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 05/21/2024 09:27 AM - 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: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)


This requirement is not met as evidenced by: 87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. S1 is missing forms LIC 501 and LIC 508. S2 is missing forms LIC 501 and 503. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
1
2
3
4
Administrator will submit complete staff forms to the LPA by the POC 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/21/2024 09:27 AM - 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: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)


This requirement is not met as evidenced by: 87412 (a)(11) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. S2 has incomplete health screening form. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2024
Plan of Correction
1
2
3
4
Administrator will submit complete health screening form for S2 by the POC
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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/21/2024 09:27 AM - 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: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1).


This requirement is not met as evidenced by: Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met by evidence of:
Deficient Practice Statement
1
2
3
4
Based on records review Staff 1 and Staff 2 are not cleared.
Civil penalties are being assessed in the amount of $500.00 for each staff.
POC Due Date: 05/21/2024
Plan of Correction
1
2
3
4
Administrator shall ensure that all staff obtain a Criminal Record Background Clearance and are associated to the facility prior to employment. Uncleared persons cannot return to work until they are cleared and associated to the facility.
Submit copies of Livescan and transfer requests by POC due date (tomorrow).
Type A
Section Cited
CCR
87533(e)(2)


This requirement is not met as evidenced by: Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met by evidence of:
Deficient Practice Statement
1
2
3
4
Based on records review S1 and S2 are NOT associated to this facility.
Licensee shall ensure all staff are cleared and associated to the facility prior to beginning employment.
POC Due Date: 05/21/2024
Plan of Correction
1
2
3
4
Administrator will provide proof of association for S1 and S2 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5