197610396-4-11-2024-31-AS-MSPH-D48TSX-20240411145949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610396
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:01:46 PM

Document Has Been Signed on 04/11/2024 03:01 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 V		FACILITY NUMBER:	197610396
ADMINISTRATOR:	DE LAS ALAS, NICOLE		FACILITY TYPE:	740
ADDRESS:	5542 LAS BRISAS TERRACE		TELEPHONE:	(707) 688-5606
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Bobby Manalansang		TIME COMPLETED:	02:00 PM

NARRATIVE

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On 4/11/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by two staff members. The Administrator, Nicole De Las Alas was called by the staff member. LPA stated the purpose of the visit was to conduct an annual inspection. The staff members confirmed there are six residents. The facility is licensed for five (5) non-ambulatory and one (1) bedridden resident.

LPA and the staff member toured the facility at 10:30 am until 11:00 am.

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

Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were securely locked in a kitchen cabinet. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable. The medications were locked in a kitchen cabinet along with the first aid kit.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate was closed and was not locked. Comfortable seating is also located in the backyard. The hot tub did not contain water and was properly covered.

Garage – The garage was locked and was organized.

Continued on 809-C

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 V	FACILITY NUMBER: 197610396
	VISIT DATE: 04/11/2024

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

Laundry Room: The laundry room was locked

Bathrooms: There are three (3) bathrooms which contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. The water temperature was recorded to be 121.4 Degrees F at 10:50 am

Additional Hallway Closet - LPA observed the clean linens were located in a closet and another locked closet contained the hygiene items.

Staff Room: The staff room was locked.

Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 11:00 am and were operable.

LPA Spaeth reviewed the resident files at 11:10 am until 11:51 am. LPA reviewed staff files at 12:20 pm until 1:00 pm. LPA reviewed the medications at 1:00 pm until 1:20 pm.

Based upon Title 22 Regulations, the following deficiency is 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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2024 03:01 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 V	FACILITY NUMBER: 197610396
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(2)

87303 Maintenance & Operation (2) Faucets used by residents for personal care…shall deliver hot water. Hot water temperature…shall be maintained to....regulate the temperature of hot water…to attain a temperature of not less than 105 degrees…& not more than 120 degrees F… This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above. The water temperature was recorded as 121.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2024
	Plan of Correction
1 2 3 4	During LPA's visit, the hot water temperature was turned down at 10:55 am. LPA tested the water temperature in the resident's bathroom at 12:15 pm and the water temperature was 120.1 degrees F.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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