197610211-1-4-2024-31-AS-MCAA-CZ73UD-20240104173318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610211
Report Date: 01/03/2024
Date Signed: 01/04/2024 05:34:29 PM

Document Has Been Signed on 01/04/2024 05:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KITTRIDGE RCFE		FACILITY NUMBER:	197610211
ADMINISTRATOR:	MARTIR, FRANCIS		FACILITY TYPE:	740
ADDRESS:	20702 KITTRIDGE ST		TELEPHONE:	(818) 854-6745
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 6	DATE:	01/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	James and Susan Olalia		TIME 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	In conjunction with a Case Management (CM) visit, Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, James and Susan Olalia, and explained the reason for the visit. At approximately 10:42am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected. There are two (2) carbon monoxide detectors, one in the living room and one in the hallway, by resident rooms, that functions properly. The fire extinguisher is located in the kitchen. 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 and were inaccessible during the inspection. The laundry area is located by the kitchen. No detergents or toxins were observed accessible. LPA also did not observe any cleaning supplies accessible in the kitchen. Bedrooms: There are four (4) bedrooms designated for residents' use. Room 1 and Room 3 are shared, while room 2 and 4 are private. Room 1 is approved for bedridden. Passageways were free of obstruction during the time of the visit. All bedrooms, in use by residents were 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 at 114 degrees Fahrenheit. LPA did not observe any cleaning supplies in either bathrooms during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Floors were clean. Furniture were in good repair. Entry and exits were clear of obstruction.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KITTRIDGE RCFE	FACILITY NUMBER: 197610211
	VISIT DATE: 01/03/2024

NARRATIVE

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Staff Room/Quarters: Staff quarters is located next to the laundry area by the kitchen. Resident medications and medication records are stored inside staff quarters. There is a bed inside the room for staff to rest in. Staff quarters remains locked at all times. No resident access.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area, both front and back was free of hazards. There is an external gate that leads into the property, that remains unlocked at all times. The garage is detached, and is located at the front of the home. The garage is only used for storage. It is locked at all times.

Resident Files: Resident files are stored locked in a kitchen cabinet. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also stored locked in a kitchen cabinet. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records are kept in staff quarters. Medications were reviewed for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/04/2024 05:34 PM - It Cannot Be Edited

Created By: Michael Cava On 01/03/2024 at 12:11 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: KITTRIDGE RCFE	FACILITY NUMBER: 197610211
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: During record review, LPA did not observe staff training was provided to satisfy this section of the regulations
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [2] staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	As POC, licensee will conduct training to address this section of the regulation. As proof training is completed, the licensee will submit a copy of the training log, attendance sheet, date and training topic to the licensing agency by 01/17/24

Type B

Section Cited

CCR

87411(d)

All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: During record review, licensee did not provide staff training to address this section of the regulation.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [2] out of [2] staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/17/2024
	Plan of Correction
1 2 3 4	As POC, licensee will conduct training to address this section of the regulation. As proof training is completed, the licensee will submit a copy of the training log, attendance sheet, date and training topic to the licensing agency by 01/17/24.

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 Miller

LICENSING EVALUATOR NAME:

Michael Cava

LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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