197610166-8-11-2024-31-AS-JGTN-D82UKW-20240811153948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610166
Report Date: 08/11/2024
Date Signed: 08/11/2024 03:40:18 PM

Document Has Been Signed on 08/11/2024 03:40 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	QUARTZ HAVEN		FACILITY NUMBER:	197610166
ADMINISTRATOR:	AYLLON, MADELEINE		FACILITY TYPE:	740
ADDRESS:	7250 QUARTZ AVE		TELEPHONE:	(626) 373-4386
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Dunhill Tolentino - Staff		TIME COMPLETED:	03:45 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) Gary Tan, initially met with staff Dunhill Tolentino for a One (1) Year Required visit for this facility. Mr. Tolentino called the administrator and purpose of the visit was stated. Administrator Medelyn Ayllon designated Mr. Tolentino to sign the report. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 12:35 PM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) additional bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, all of which may be bedridden. Hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were filled and last inspected on 03/21/24. The facility is equipped with fire sprinkler system. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUARTZ HAVEN	FACILITY NUMBER: 197610166
	VISIT DATE: 08/11/2024

NARRATIVE

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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. There is no garage at the facility, only driveway at the front. Laundry area is located adjacent to the kitchen. Laundry area was observed to be locked. Laundry detergents are locked in the laundry area.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in a locked cabinet below the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 111.5°F to 113.7°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed. Resident #1 (R1) has no admission agreement and medical assessment on file. Resident #2 (R2) has a diagnosis of dementia and no current medical assessment on file. Staff records: LPA conducted a complete file review of staff record.

Disaster drill was last conducted on 07/01/2024. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2024 03:40 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: QUARTZ HAVEN	FACILITY NUMBER: 197610166
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 in one (1) out of five (5) residents records reviewed has no medical assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have R1 obtain an LIC 602 and submit to CCL on or before the POC date.

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 in one (1) out of five (5) residents' record reviewed has no signed admission agreement on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain and ensure that R1 had an admission agreement and send a copy to CCL on or before 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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2024

LIC809 (FAS) - (06/04)

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