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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610178
Report Date: 06/27/2023
Date Signed: 06/27/2023 04:31:55 PM


Document Has Been Signed on 06/27/2023 04:31 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:ANNIKA GRACE CARE HOMEFACILITY NUMBER:
197610178
ADMINISTRATOR:BATUIAN, JOZAM LATAYANFACILITY TYPE:
740
ADDRESS:6338 W AVENUE J11TELEPHONE:
(818) 802-8004
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 2DATE:
06/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jozam Latayan BatulanTIME COMPLETED:
04:45 PM
NARRATIVE
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On 06/27/2023 in conjunction with an initial complaint visit control number 31-AS-20230619091039, Licensing Program Analyst (LPA) Evelin Rios completed an unannounced CASE MANAGEMENT- Deficiencies visit. LPA met with Administrator Jozam Latayan Batulan, explained the purpose of the visit.

At 12:15 p.m. LPA reviewed two (2) out of two (2) resident records. Review revealed resident #1(R1) and resident#2 (R2) records are incomplete by missing the following: Identification and emergency information, pre- admission appraisal, needs and services and functional capabilities. Administrator confirmed they did not complete documentation missing in residents' records.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D).

Copy of this report provided, appeal rights given. Exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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 06/27/2023 04:31 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: ANNIKA GRACE CARE HOME
FACILITY NUMBER: 197610178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
CCR
87506(a)

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87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Licensee will document ID/Emergency Information, Functional Capabilities, Reappraisals, and Incident Reports for R1 and R2. Submit copies to LPA by POC due date. If R1 is transfered out of the facility the Licensee will notify LPA of such by POC due date.
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Based on interviews and record review, the licensee failed to ensure complete and required records were created and kept for two(2) out of two (2) residents in care which poses a possible health and safety risk to residents 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: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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