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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203062
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:49:25 PM

Document Has Been Signed on 11/14/2024 02:49 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FRANK CALA HOUSEFACILITY NUMBER:
198203062
ADMINISTRATOR/
DIRECTOR:
RAFAEL LOPEZFACILITY TYPE:
736
ADDRESS:8500 HANNA STREETTELEPHONE:
(818) 347-1777
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jesley Lopez-CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 11/14/24 at 10:15am an unannounced annual visit was conducted by Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Huma Rahimi . Upon arrival, LPAs met with the caregiver Jesley Lopez, who granted access to the facility. LPAs explained the reason for the visit. Shortly after the House Manager, Esmeralda Puente arrived and helped with physical plant tour and staff/residents files.

During today's visit, LPAs conducted a physical plant walk through, at approximately 11:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.
The following was observed:

Facility is licensed for capacity of six (6) residents. There are four (4) bedrooms in the facility of which four (4) bedrooms designated for residents’ use. Bedrooms are appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility. LPAs observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 11:15 to be 115°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. Facility has an office space where all residents/staff files are being stored.

LPAs observed that the medication are kept in the living room in a locked cabinet and inaccessible to residents in care, however, review of R3's random medication revealed that the facility started a new bottle of Levetiracetam 500 MG (Seizure Medication), on 08/17/2024 with a quantity of sixty (60) tablets. The bottle was finished on 09/15/2024. A new bottle of the same medication was filled on 09/19/2024 with quantity of 180 tablets. LPAs observed that there was a gap/discrepancy of four days between the two bottles. LPAs asked the House Manager and the staff for explaining and both staff and the House Manager could not provide any answers.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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Document Has Been Signed on 11/14/2024 02:49 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 11/14/2024 at 01:12 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: FRANK CALA HOUSE

FACILITY NUMBER: 198203062

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87915(a)(5)
Storage of Medications
(a) The following requirements shall apply to medications which are centrally stored: (5) The licensee shall ensure that each medication container includes the following information and shall maintain for each resident a record of centrally stored prescription medications which are to be retained for at least three years:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and record review, the licensee did not comply with the section cited above in one (1) out of six (6) residents prescribed medications records, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Licensee/Administrator agreed to schedule vendorized training for all staff by 11/18/2024 and submit CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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: FRANK CALA HOUSE
FACILITY NUMBER: 198203062
VISIT DATE: 11/14/2024
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Additionally, LPAs also observed Centrally Stored Medication (LIC 622) records for R3 and did not observe staff filling the form when the medication start date for the new bottle. A deficiency will be cited. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift.

LPAs observed the kitchen area, there was sufficient stock of one-week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored with expiration date labels on them. Food storage and preparation areas are clean and inaccessible to pests. LPAs observed knives and sharp objects were stored in a locked drawer inaccessible to residents in care. The kitchen has a working gas stove, microwave, three (3) refrigerators, and freezer. Extra emergency food was properly stored inside the storage cabinet.



The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:45am to be 73°F. No obstructions and or tripping hazards throughout the facility found.

The Facility has three (3) fire extinguisher, LPAs observed it was last purchased on 2/17/2024. Laundry room is located in the garage. LPAs observed all chemicals and detergents are kept locked inside the garage cabinets, are under supervision, and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 1:00pm and observed to be functional. LPAs observed a clean covered patio and backyard furniture to accommodate six (6) residents. The backyard is properly fenced. Exit areas are free of obstructions and hazards, exit gates were unlocked and easily accessible. LPAs checked inside of the locked shed it was used for facility maintenance purposes. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. No bodies of water observed.

Between 11:10am to 1:00pm, LPAs reviewed records and files of six (6) residents and four (4) staff/caregivers. A review of staff and resident records appeared to be complete. Residents' files contain a signed admission agreements and a medical assessment, and all other required documentarians. A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances, LPAs reviewed LIC501s, LIC503s, LIC9052s, and Training and Education certificates. There are no residents with prohibited conditions residing at the facility.
Continue on LIC809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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: FRANK CALA HOUSE
FACILITY NUMBER: 198203062
VISIT DATE: 11/14/2024
NARRATIVE
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First-aid has all proper items and is current. New manual is also available.
Facility also provides activities to the residents. LPAs observed puzzles, coloring books, crayons, and board games organized and stored inside the living room cabinet.
An emergency exit plan/sketch is posted along the hallway with other posting requirements.

The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.


LPAs collected LIC500, LIC9020, and Liability Insurance copy.

Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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