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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610205
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:20:05 PM

Document Has Been Signed on 11/13/2024 03:20 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:HUMBLE HAVEN RCFE IIIFACILITY NUMBER:
197610205
ADMINISTRATOR/
DIRECTOR:		DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:38433 ANSET DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 6DATE:
11/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Raquel Adriano & Tatiana BuendiaTIME VISIT/
INSPECTION COMPLETED:
02:45 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
LPA Spaeth conducted an unannounced visit regarding complaint number 31-AS-20241107085345. LPA was greeted by two staff members. LPA toured the facility at 10:45 am until 11:10 am.

At 10:55 am, LPA observed the medication cabinet was not locked. LPA Spaeth informed the staff members the medication cabinet must be locked at all times. A staff member locked the cabinet at 10:58 am.

Based upon LPA's observations, the following deficiency was issued.

Exit interview conducted, appeal rights were discussed, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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 11/13/2024 03:20 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/13/2024 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HUMBLE HAVEN RCFE III
FACILITY NUMBER: 197610205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
87465(h)(2)

1
2
3
4
5
6
7
87465 Incidental Medical & Dental Care (h) the following... shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place….This requirement is not met as evidenced by:
1
2
3
4
5
6
7
During LPA's visit, a staff member locked the cabinet.
8
9
10
11
12
13
14
Based on LPA’s observation, the licensee did not comply with the section cited above. LPA observed the medication cabinet was not locked which poses an immediate health and safety risk to persons in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2