197610201-2-16-2024-31-AS-MSPH-D2HTXQ-20240216140731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610201
Report Date: 02/16/2024
Date Signed: 02/16/2024 03:43:49 PM

Document Has Been Signed on 02/16/2024 03:43 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:	4 ALL SENIORS CARE HOME		FACILITY NUMBER:	197610201
ADMINISTRATOR:	SAMANIEGO, JOHN ROEL		FACILITY TYPE:	740
ADDRESS:	744 VANDALWAY		TELEPHONE:	(661) 400-4948
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	02/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Marita Samaniego		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator, Marita Samaniego arrived at 10:00 am. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents living in the facility. The facility is licensed for six (6) non-ambulatory residents and one bedridden resident. The facility has a hospice waiver for six residents.

LPA Spaeth and the Administrator toured the facility at 10:00 until 10:30 am..

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The knives were locked in a kitchen drawer and the cleaning solutions were locked underneath the kitchen sink.

Laundry Room – The laundry room was locked and contained the washer/dryer and the laundry detergent.

Garage – LPA observed an additional refrigerator which contained milk and frozen food items.

Bathrooms: There are two (2) resident bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, slip resistant mats, grab bars, paper towels and trash bins with lids. The water temperature was tested at 10:40 am and was 133.0 degrees F.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
	VISIT DATE: 02/16/2024

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Resident Rooms: There are five resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean..

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:45 am and were operable.

LPA reviewed resident files at 11:00 am until 12:00 noon and reviewed staff records at 1:00 pm until 1:20 pm.

Based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/16/2024 03:43 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: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(2)

87303 Maintenance & Operations (2) Faucets used by residents for personal care…shall deliver hot water. Hot water temperature controls shall be maintained…to attain a temperature of ….not more than 120 degree F.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation of the water temperature measuring at 133.0 derees F, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	The water temperature was adjusted by the Administrator. LPA Spaeth observed the water temperature was 107.0 degrees F at 12:45 pm. .

Type A

Section Cited

CCR

87202(a)

87202 Fire Clearance (1) All facilities shall maintain a fire clearance approved by the city..or...county fire department,.... prior to accepting or retaining the following types of persons...(2) bedridden persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, R1 is a bedridden resident who is not residing in Bedroom 1. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/20/2024
	Plan of Correction
1 2 3 4	Resident 1 will be moved to Bedroom 1. The Administrator will send a snapshot of R1 residing in Bedroom 1.

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) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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