<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801561
Report Date: 09/25/2023
Date Signed: 09/25/2023 02:59:51 PM

Document Has Been Signed on 09/25/2023 02:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRAFFIC WAY HOUSEFACILITY NUMBER:
405801561
ADMINISTRATOR:DEBBIE STARLINGFACILITY TYPE:
735
ADDRESS:5000 TRAFFIC WAYTELEPHONE:
(805) 466-0721
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 14CENSUS: 6DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Debbie Starling, AdministratorTIME COMPLETED:
03:15 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
On 9/25/23 at 11:20 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Annual/Required visit to the facility listed above. LPA met with Staff #1 (S1) and Debbie Starling, Administrator, and explained the purpose of the visit.

LPA toured the facility with S1. There was one client in the facility during the visit who was sick. S1 says all other clients are at day program. The facility is maintained in conformity with state fire marshal regulations. The smoke detectors and carbon monoxide detector were tested and functioning properly. Fire extinguishers (4) are located in the hallways near client bedrooms, in the kitchen, and across from the office. Extinguishers are fully charged and were inspected on 10/5/22. There are no pools nor bodies of water. There are no firearms or dangerous weapons stored. Hot water temperatures were recorded in the kitchen and resident bathrooms. Temperatures in the kitchen and bathroom near bedroom #6 registered at 116.1 F and 116.4 F degree, however, the water temperature in the bathroom across from staff bedroom recorded at 143 F degrees. Deficiency cited. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, sanitary and in good repair for the safety and well-being of clients, employees, and visitors. One exception is the oven door has food spills on it. Licensee will clean and send a photo to LPA by 10/2/23. Another exception are screens missing from the sliding glass door and window of bedroom #7. Licensee will repair/replace and send photos to LPA by 10/2/23. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Disinfectants and cleaning solutions are inaccessible to clients. The facility has adequate emergency supplies and first aid supplies. Facility is a comfortable temperature. Outdoor walkways are free from obstruction and the facility has an outside covered patio area for individuals to use. The facility has resident rights, CCLD complaint poster, and emergency disaster plan posted, however, the facility is missing a non-discrimination statement and the emergency disaster plan needs to be updated to the nine-page LIC 610D. Deficiency cited. Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 09/25/2023 02:59 PM - It Cannot Be Edited


Created By: Darlene Chavez On 09/25/2023 at 02:23 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRAFFIC WAY HOUSE
FACILITY NUMBER: 405801561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that water temperatures in one out of three faucets tested was not in compliance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2023
Plan of Correction
1
2
3
4
Licensee will adjust water heater and send a video showing water temperature in compliance to LPA by 9/26/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/25/2023 02:59 PM - It Cannot Be Edited


Created By: Darlene Chavez On 09/25/2023 at 02:23 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRAFFIC WAY HOUSE
FACILITY NUMBER: 405801561

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in the Emergency DIsaster Plan (LIC 610D) was not completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2023
Plan of Correction
1
2
3
4
Licensee will update the Emergency Diaster Plan (LIC 610D) and send to LPA by 10/2/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRAFFIC WAY HOUSE
FACILITY NUMBER: 405801561
VISIT DATE: 09/25/2023
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
26
27
28
29
30
31
32
The facility has staff (2) occupying bedrooms listed as client bedrooms on the facility sketch and a client occupying a staff bedroom. Licensee will update the facility sketch and obtain a new fire clearance and send the updated facility sketch and fire clearance report LPA by 10/2/23 or as soon as the fire department can conduct the visit.

LPA reviewed (4) staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. All files were in compliance.

Emergency disaster drills are conducted quarterly.

LPA reviewed five (5) client files for current health records, needs and services plans, signed admission agreements and personal rights. All client files are complete and in-compliance.

Clients’ centrally stored medications are kept in the locked office. Medications are given as prescribed by doctors’ orders.

Exit interview conducted, deficiencies cited, and the report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4