198602362-12-29-2023-31-AS-LNCA-CYYQM5-20231229111659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602362
Report Date: 12/28/2023
Date Signed: 12/29/2023 11:17:27 AM

Document Has Been Signed on 12/29/2023 11:17 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:	HARRIET HOUSE		FACILITY NUMBER:	198602362
ADMINISTRATOR:	EASTON, ALYCE		FACILITY TYPE:	735
ADDRESS:	24 W HARRIET		TELEPHONE:	(626) 794-4103
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 12		CENSUS: 8	DATE:	12/28/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Magdalena Estrada- Administrator		TIME COMPLETED:	01:45 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. LPA met with staff Graciella Rincon at 10:35 am and was advised for the purposed of the visit, around 11:12 am the administrator Magdalena Estrada arrived. At 11:12 am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The facility has two houses that has a total of six (6) bedrooms and six (6) bathrooms. The smoke alarms are operational and their carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and hallway with the charge date is 8/23/2023 for both houses. During the visit the facility is at 66 degrees Fahrenheit. The facility is fire cleared for twelve (12) ambulatory. The facility offers level 4 care ti 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. Food storage and preparation areas are clean and inaccessible to pests. Knives were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in the kitchen cabinets. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away. Bedrooms: There were total of six (6) bedrooms designated for residents' use, each house has three (3) bathrooms in the property. For house #1, bedroom #2 is shared and is in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #1 and #3 are properly furnished and occupied by private residents. For house #2, bedroom #2 is shared and is in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #1 and #3 are properly furnished and occupied by private residents. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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: HARRIET HOUSE	FACILITY NUMBER: 198602362
	VISIT DATE: 12/28/2023

NARRATIVE

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Bathrooms: There are three (3) bathrooms designated for residents' use in each house. Both bathrooms were properly supplied and had functional fixtures. Bathroom #1 hot water temperature was measured at 110 degrees Fahrenheit and bathroom #2 measured 105 degrees Fahrenheit. Bathroom #1 is located in beside bedroom #1. Bathroom #2 is located across bedroom #2. Bathroom #3 is located beside bedroom #3. Cleaning supplies are being stored in a locked cabinet in the cabinet the dining room. Towels and washcloths are not shared. There was enough clean linen available in the cabinets in the hallway.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Furniture in common area was observed to be in good repair. There is no fire place in the facility. No obstructions and or tripping hazards throughout the facility. Residents dining table fits enough for six (6) for both houses. Office is located in the kitchen area beside the patio exit. The laundry area is located by the across bedroom #1 for both houses.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. There is no garage. There are no issues with Fire Clearance.

Infection control: LPA reviewed 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.

Laundry service: There is enough linen available to change weekly or more if need.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA was not able to conduct a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records are not available to checked for expired or missing certificates and clearances. The administrator file was not reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training. Therefore, LPA will need to conduct a file review of staff for criminal record clearances and current First Aid some other time.
Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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: HARRIET HOUSE	FACILITY NUMBER: 198602362
	VISIT DATE: 12/28/2023

NARRATIVE

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Medications: Medication and Medication Records (MMR) were review for proper documentation. 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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, Type B and technical violations are cited for deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/29/2023 11:17 AM - It Cannot Be Edited

Created By: Leslie Ngo-Castaneda On 12/28/2023 at 12:55 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: HARRIET HOUSE	FACILITY NUMBER: 198602362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80022(e)(4)

Plan of Operation

(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/04/2024
	Plan of Correction
1 2 3 4	Please have staff files available for LPA to review.

Type B

Section Cited

CCR

80066(a)(12)(B)1

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/04/2024
	Plan of Correction
1 2 3 4	Please have staff files available for LPA to review.

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: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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