405801674-2-15-2024-29-AS-EMIR-D2GT9K-20240215133203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801674
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:32:16 PM

Document Has Been Signed on 02/15/2024 01:32 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CALUYA'S RESIDENTIAL CARE HOME II		FACILITY NUMBER:	405801674
ADMINISTRATOR:	JASON Y. CALUYA		FACILITY TYPE:	740
ADDRESS:	1160 15TH STREET		TELEPHONE:	(805) 534-9239
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	4	CENSUS: 2	DATE:	02/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:58 AM
MET WITH:	Jason Caluya, Administrator		TIME COMPLETED:	01:41 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) Miller arrived at 8:00 a.m. to conduct a one-year annual visit to the facility above. LPA met with Administrator, Jason Caluya, and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 3 resident bedrooms, and 2 bathrooms. Facility currently occupies 2 residents and employs 3 full time staff, one of which is the Administrator. LPA Miller was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and working properly during visit. Fire extinguishers were purchased on September 14, 2023. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions are inaccessible to residents in care locked in cabinet above washer and dryer. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use and front patio has plenty of shade thought the use of canopies and umbrella shades. The facility has telephone and internet service for resident use. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALUYA'S RESIDENTIAL CARE HOME II	FACILITY NUMBER: 405801674
	VISIT DATE: 02/15/2024

NARRATIVE

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Incidental Medical and Dental: LPA Miller conducted a review of prescriptions for two residents. Resident 1 was given 100 Mg Tablet of Metoprolol Succinate, despite being expired since September 30, 2023 and Triamcinolone Acetonide .1% topically cream, despite being expired since September 2023.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on June 1, 2024. The facility is approved for a capacity of four. The fire clearance is granted for 4 non-Ambulatory. Hospice is approved for one.

Staffing: The facility currently employes 3 full time staff, one of which is the Administrator. Staff files were reviewed. Current Administrator Certificate expires July 15, 2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed two resident files for signed Admission Agreements, medical assessments and appraisal & needs service plans.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices.
Disaster Preparedness: Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has two residents receiving Home Health services. Exit door alarms are working.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/15/2024 01:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALUYA'S RESIDENTIAL CARE HOME II	FACILITY NUMBER: 405801674
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(i)

(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: 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 2 out of 11 medications were expired, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/19/2024
	Plan of Correction
1 2 3 4	Administrator agreed to speak with R1's daughter to not bring multiple back ups of medication and will sign a statement that he will agree to clear out prescriptions once a month.

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC809 (FAS) - (06/04)

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