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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850037
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:39:32 PM

Document Has Been Signed on 10/15/2024 03:39 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:LA LOMA HOMEFACILITY NUMBER:
405850037
ADMINISTRATOR/
DIRECTOR:		JUSTIN A PENRODFACILITY TYPE:
735
ADDRESS:1151 LA LOMA DRTELEPHONE:
(805) 723-5104
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:36 PM
MET WITH:Marisa CardonaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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 At 1:36 pm on 10/15/24, Licensing Program Analyst (LPA) Rankin and Tri Counties Regional Center (TCRC), Quality Assurance Specialist (QA) Miguel Magana arrived at the facility unannounced to conduct a Case Management (CM) visit based on a self reported incident by the facility. LPA and QA met with Administrator Marisa Cardona explained the reason for the visit.

A TCRC incident report dated 09/13/24 reported that on 8/25/24 all four (4) clients were “left unsupervised in a company van while both staff went into an unknown apartment for about 30 minutes. During the CM visit LPA and QA discussed the event. Administrator stated clients who were able to communicate confirmed being left alone and one of the two staff confirmed that clients were left alone.

The LPA reviewed three (3) staff files, and all four (4) client files. All Physician reports for client’s state that they cannot leave the facility unsupervised. There is one client currently that requires 1:1 support.

Based on incident report, documentation, and interviews, facility failed to prevent clients being left unsupervised which did not meet clients' individual needs. Although the Licensee and administrator have addressed the incident with additional training with all staff, termination of staff involved in the incident, and putting other protocol in place to protect future incidents, a deficiency will be issued based on clients’ needs stated in their LIC 602 report that they require supervision when leaving the facility. For Plan of Correction the facility has completed an internal review, submitted evidence of training being done for all staff, and terminated staff involved in the incident.

Exit interview conducted, Administrator will be given a copy of the deficiency, appeal rights and this report.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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Document Has Been Signed on 10/15/2024 03:39 PM - It Cannot Be Edited


Created By: Melisa Rankin On 10/15/2024 at 12:56 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: LA LOMA HOME
FACILITY NUMBER: 405850037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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The licensee shall ensure all staff receive training regarding regulation 80065 and understand staff can never leave clients unattended. Documentation statement that all current staff have recieved the
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Based on documentation and interviews, the licensee failed to comply with the section cited above in that 4 clients were left unsupervised on 8/25/24 in a van for approximately 30 minutes.
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training shall be submitted by 11/8/24.

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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:Kelly Burley
LICENSING EVALUATOR NAME:Melisa Rankin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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