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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802304
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:19:02 PM

Document Has Been Signed on 03/20/2025 03:19 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:A HEAVENLY COMMUNITIES AFACILITY NUMBER:
405802304
ADMINISTRATOR/
DIRECTOR:
JIMENEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:2025 UNION ROADTELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Backup Administrator - Karla SanchezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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At 8:25am on 03/20/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to the facility to conducted the annual facility inspection. LPA met with backup Administrator Karla Sanchez, announced who he was and the reason for the visit.
LPA noted that the facility is one of four facilities on approximately 2 acres that is gated and there is a recreation building and expansive open courtyard with shaded areas for residents and visitors. During todays inspection, LPA conducted the annual inspection of the facility listed above.
Backup Administrator and LPA conducted a full facility tour. LPA noted the facility has 6 bedrooms and 7.5 bathrooms. The bedrooms are single occupancy each with a full private bathroom. The facility has a great room consisting of a living room, dining room and kitchen. There is a designated salon room with full bathroom for the residents of this facility and other 3 facilities on the property. There is a public use half bathroom at the facility entry. The medications are stored in a locked medication cart in the facility hallway. There are combo smoke/carbon monoxide detectors throughout the facility that are hardwired with backup battery. Apex Fire and Safety conducted a successful annual compression test for the fire sprinkler system on 12/03/2024. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. LPA observed fire extinguishers that were tagged current and in the green compression range serviced on 12/03/2024. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR) and found no violations. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy freely. LPA noted that all resident meals are prepared and cooked in this facility in a separate kitchen located through a door next to the salon and delivered to each facility by hand. LPA observed at least two days of perishable foods and seven days of non-perishable on hand for this facility. LPA conducted a staff and resident file review. During the staff file review LPA noted 2 of 5 staff files not containing a health screening.
LPA and backup administrator conducted a review of the annual care tool modules.
Exit interview done, annual report, citation, and appeal rights were printed and provided to backup administrator.
Kelly BurleyTELEPHONE: (805) 562-0413
Garrett Haner-TomaskoTELEPHONE: (805) 450-0283
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 03/20/2025 03:19 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: A HEAVENLY COMMUNITIES A

FACILITY NUMBER: 405802304

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff records which poses a potential health, safety or personal rights risk to persons in care. LPA noted 2 of 5 staff records did not have a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. Staff were unable to locate.
POC Due Date: 04/03/2025
Plan of Correction
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Backup Administrator agrees to obtain health screenings for the 2 staff and email them to the LPA by 4/3/2025.
Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly BurleyTELEPHONE: (805) 562-0413
Garrett Haner-TomaskoTELEPHONE: (805) 450-0283

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025

LIC809 (FAS) - (06/04)
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