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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610415
Report Date: 12/01/2024
Date Signed: 12/01/2024 04:12:39 PM

Document Has Been Signed on 12/01/2024 04:12 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:KAZOKU HOMEFACILITY NUMBER:
197610415
ADMINISTRATOR/
DIRECTOR:		SADAMOTO, AKIKOFACILITY TYPE:
740
ADDRESS:9600 AMBOY AVETELEPHONE:
(424) 237-4914
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 5DATE:
12/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Douglas Lee - Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan, met with Co Administrator Douglas Lee for a One (1) Year Required visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 12:50 PM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has seven (7) bedrooms and six (6) bathrooms currently occupying five (5) residents. Two (2) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, three (3) of which may be bedridden on room #4 and #5. Hospice waiver for three (3) residents.

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There are dual smoke/carbon monoxide installed at the facility. Fire extinguisher is located upon entry on the main door and bedroom hallway and observed be full and last bought on 12/01/24. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2024
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: KAZOKU HOME
FACILITY NUMBER: 197610415
VISIT DATE: 12/01/2024
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(continued on LIC 809-C)

There is no garage at the facility, only car ports at the front Laundry room is located adjacent to the kitchen. Laundry detergents, cleaning agents and other toxins are stored in a locked in the laundry room. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.



The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 113.9°F to 118.7°F Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication was kept in a locked kitchen cabinet. There were two (2) complete first aid kits located in the medication cabinet.

Client records: Client records are reviewed. Resident #1 has a diagnosis of dementia and Medical Assessment was last done on 06/09/23. Staff records: LPA conducted a complete file review of staff records, two (2) out of three (3) staff reviewed did not have first aid training certificate on file. Disaster drill was last conducted on 11/03/24. Required posting observed in facility (complaint hot line poster, LTCO).

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2024 04:12 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 12/01/2024 at 03:09 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: KAZOKU HOME
FACILITY NUMBER: 197610415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff records reviewed did not have first aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Administrator agreed to send the staff to a first aid training and submit a copy of the certificate to CCL on or before the POC date.
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) resident with dementia diagnosis out of total of five (5) residents records reviewed did not have a current medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Administrator agreed to obtain a current medical assessment fot dementia resident and submit a copy to CCL on or before the POC date.
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:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2024


LIC809 (FAS) - (06/04)
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