197801131-1-5-2024-31-AS-LNCA-CZ7QJJ-20240105111250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801131
Report Date: 01/04/2024
Date Signed: 01/05/2024 11:13:20 AM

Document Has Been Signed on 01/05/2024 11:13 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CASA DEL SOL		FACILITY NUMBER:	197801131
ADMINISTRATOR:	LORCA, ANITA		FACILITY TYPE:	735
ADDRESS:	2312 NORWALK AVENUE		TELEPHONE:	(323) 258-0151
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY: 6		CENSUS: 4	DATE:	01/04/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Valentin Dizon- Administrator		TIME COMPLETED:	01:30 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	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. Josephone Segundo who is the staff met with LPA, explained the reason for the visit. Approximately, around 10:04am Valentin Dizon who is the designated administrator arrived. At 11:04 am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and patio. The charge date is 12/27/2023. During the visit the facility is at 68 degrees Fahrenheit. The facility is fire cleared six (6) non-ambulatory residents.. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. The menu was posted for review (ARF), snacks and beverages are available for the resident in the facility when they want. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away. LPA discussed special diets for diabetic resident. Bedrooms: There were three (3) bedrooms designated for residents' use. Room #1 is vacant for shared residents. Room #2 and room #3 of the bedrooms are shared, is used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Two (2) staff bedroom are also available for live-in staff. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA DEL SOL	FACILITY NUMBER: 197801131
	VISIT DATE: 01/04/2024

NARRATIVE

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Bathrooms: There are three (3) bathroom in the facility. One (1) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 107.7 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1. Bathroom #2 and bathroom #3 is for staff used that is located inside the staff room and beside bedroom #2 in the hallway. There was enough clean linen available in the cabinets. Bathrooms needs to be clean and tidy to avoid mold, LPA observed soap scums in the shower area and shower chair. Technical violation is given.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. There is no fire place in the facility. Residents dining table fits enough for four (4). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry area in the garage and are kept secured. The facility does not have a swimming pool or body of water. The garage is storage for and is used for parking.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the laundry area and is located by the garage.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is located upon entrance of the facility Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Proper documentation such as LIC 308 and LIC 9052 needs to filed in staff folder. Technical violation has been issued to facility.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA DEL SOL	FACILITY NUMBER: 197801131
	VISIT DATE: 01/04/2024

NARRATIVE

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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPA. Planned activities are offered. LPA reviewed two (2) of the four (4) residents funds and observed receipts and funds balanced. Incidents reports were not reported for COVID positive on 12.16.2023; therefore type B violation is cited.

Facility is not within CA code of Regulations Title 22 or Health and Safety Code. Type B violation and technical violation were found and cited, exit interview conducted, copy of report has been issued and discussed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/05/2024 11:13 AM - It Cannot Be Edited

Created By: Leslie Ngo-Castaneda On 01/04/2024 at 12:42 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: CASA DEL SOL	FACILITY NUMBER: 197801131
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)(1)

Client Medical Assessments

(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 on residents and staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Facility needs to send incident report for COVID 19.

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:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Leslie Ngo-Castaneda

LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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