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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610333
Report Date: 03/22/2024
Date Signed: 04/12/2024 03:06:56 PM


Document Has Been Signed on 04/12/2024 03:06 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 IVFACILITY NUMBER:
197610333
ADMINISTRATOR:DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:4036 TOURNAMENT DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 6DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joselito BihasaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by two caregivers (S1 and S2). LPA observed a third person and was informed it was a family member of the two caregivers. Upon entry at 9:15 am, LPA observed the delayed egress notification was not working at the front door. LPA stated the purpose of the visit was to conduct an annual inspection. The staff confirmed there are six residents. The facility is licensed for five non-ambulatory residents and one (1) bedridden resident.
LPA Spaeth reviewed resident records at 10:00 am to 11:00 am. LPA Spaeth & caregiver toured the facility at 11:00 to 11:30 am.

Living Room. - When entering the facility, the living room is located to the right and is a room with three walls. LPA observed a curtain was used as a door. LPA observed the room is used as a staff room and contained two twin beds. At 9:30 am, LPA observed staff member's medication was sitting out on a dresser. At 9:33 am, LPA observed the caregiver locked the medication in the resident's medication cabinet.

Kitchen/Family Room - LPA Spaeth observed the kitchen and family room are combined. The facility contained a two day supply of perishable food and a seven day supply of non-perishable foods. The knives were locked in a kitchen cabinet. The cleaning solutions are securely locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable.

Medication - LPA observed the resident medications, and first aid kit, are safely locked in a kitchen cabinet. The resident and staff files were also locked in the cabinet.

Delayed Egress: LPA observed the delayed egress to all exits were turned off and not working.

Continued on 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333
VISIT DATE: 03/22/2024
NARRATIVE
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Garage//Washer & Dryer – The laundry room was locked and contained the washer/dryer. The laundry soap was stored in the room. The door leading to the garage was locked. at 11:40 am, LPA observed a section of the garage was converted into a room. LPA observed a bed, microwave, portable toilet, and a person's belongings.

There is an exit out of the room to the front yard. The caregivers stated a person is renting the room. They also stated the individual uses the portable toilet at night but will go through the front door to use the restroom and shower during the day. The caregivers confirmed the resident does not receive care and supervision.

Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. Based upon the Fire Safety Inspection Request document issued by the Los Angeles Fire Department which was dated 9/2022, the facility may have five non-ambulatory residents and one bedridden resident. Bedrooms 1, 2, 3, and 4 are non-ambulatory rooms. Bedroom 5 is the designated bedridden room. LPA observed two bedridden residents living in Bedroom 1 (one) and Bedroom 3 (three).

Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. When observing bathroom two, LPA observed cleaning solutions were unlocked underneath the sink. LPA observed the caregiver moved the solutions to a locked cabinet.

Water Temperature: LPA tested the water temperature at 11:45 am which was 141.1 degrees F. LPA instructed the caregiver to adjust the water temperature to the hot water heat. LPA observed the caregiver did turn the temperature at 11:50 am.

Contd' 809-C

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 04/12/2024 03:06 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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above The water temperature was recordeded to be 141.1 Degrees F at 11:45 am which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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During LPA's visit, the caregiver reduced the water heater temperature. LPA tested the water again at 12:30 pm and the temperature was 107.0 degree F.
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The garage had been converted into a room and a resident was living in the room. Also, CCL did not receive a copy of the building permit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2024
Plan of Correction
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The Administrator has been advised to provide the building permit to LPA Spaeth via emal.
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 AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 04/12/2024 03:06 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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, there are seven residents living in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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The Administrator has been instructed to relocate the resident to another location.
Type A
Section Cited
CCR
87307(e)
Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the spa cover was not properly on the spa, .
POC Due Date: 03/22/2024
Plan of Correction
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During LPA's visit, the spa cover was placed on top of the spa. .
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 AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 04/12/2024 03:06 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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's obsevations, the licensee did not comply with the section cited above. LPA observed cleaning solutions were stored underneath an unlocked bathroom cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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During LPA's visit, the cleaning solutions were locked in a bathroom cabinet.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed there are two bedridden residents and the facility has a fire clearance for one bedridden resident. The room disgnation for a bedridden client is room 5.
POC Due Date: 03/27/2024
Plan of Correction
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The Administrator will move resident No. 2 to the correct room. The Administrator stated the Physiciani's Report for Resident No 1 is incorrect. The Administrator will obtained an new Physician's Report which will identify resident No 1 as ambulatory so that resident No. 1 can remain in Room one.
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 AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 04/12/2024 03:06 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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Spaeth's observation, the caregiver had left personal medication on a dresser which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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During LPA's visit, LPA observed the caregiver locked personal medications in the locked medication cabinet.
Type A
Section Cited
CCR
87705(k)
Care of Persons with Dementia
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The egress alarms had been turned off, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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During LPA's visit, the alarms to three exits were turned on. At 3:30 pm, LPA observ all three alarms were operable.
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 AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


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: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333
VISIT DATE: 03/22/2024
NARRATIVE
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Surrounding Grounds: The backyard contained comfortable seating. LPA observed a spa is located in backyard. The spa cover was only cover one quarter of the spa. There was no water in the spa but a portable step was located next to the spa which allows access into the spa.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 11:55 am.

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

LPA Spaeth read the report to the Administrator, Nicole De Las Alas at 3:00 pm until 3:15 pm. The Administrator stated to LPA Spaeth that the caregiver may sign the report. LPA Spaeth also informed the Administrator that an additional unannounced visit may be warranted to address the staff living in the living room area.

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

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7