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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850037
Report Date: 08/13/2024
Date Signed: 08/14/2024 06:56:28 AM

Document Has Been Signed on 08/14/2024 06:56 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 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: DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Justin Penard, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Rankin arrived at 11:05 am to conduct a 1-year annual visit to the facility above. LPA met Administrator Justin Penrod and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility is a 4 bedroom and 3 bathroom facility currently occupying 4 residents and employs 10 staff. The facility is clean, safe, and sanitary. The facility has dual smoke and carbon monoxide detectors which were tested. The lighting and lamps are sufficient for the use of the facility and for client’s comfort. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are in a locked closet off the main hallway, this door should self-lock when closed. The facility has sufficient space inside and outside for activities and visiting. The facility has an enclosed backyard for client use with plenty of shade. The facility has telephone and internet service for client use. Water temperature were within regulation requirements and the facility checks and keeps a monthly log of temperatures. Facility has a recent contract with a new pest company to ensure in their rural area the facility remains free of pest, insects, and vermin.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 4 Ambulatory.



Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/13/2024
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Staffing: The facility employes 10 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files and all required documents were present.

Personnel Records & Training: The facility keeps confidential files for each staff member. All staff had current 1st AID/CPR along with required annual training.

Clients Rights - All require postings were posted in the common area of the facility. Personal rights and Persons with disabilities, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster is posted at entry. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet is provided to each client and each client is given confidentiality and privacy.

Clients Records & Incident Reports: The facility keeps separate files on each resident confidential. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS) are done as IPP and ISP and completed quarterly and annually, TB results, Personal Rights, and Safeguard for personal property and valuables. The Facility does handle cash resources for all 4 clients in care. LPA audited all 4 clients funds with ledgers, cash, and receipts. Facility does submit incident reports to the department when required.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. A menu is posted for clients in care. Modified diets prescribed by a physician are followed for those clients in care. Cleaning solutions and equipment are stored separately than food supply. Kitchen counter top and cooking equipment were clean and free from litter, and rodents. Additional scheduled cleaning for rarely used areas is scheduled for routine maintenance.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
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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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/13/2024
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Health Related Services: Facility provides transportation to medical and dental appointments when needed. Facility provides Centrally Stored Medications to all clients in care. First Aid is provided to clients in care. Clients’ medication records were reviewed, PRN medications were checked for expiration, a missed medication with incorrectly notated on the a MAR, as well as a noted missing destruction record from 6/8/24, medication records cited.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 03/12/2024. 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.

Exit interview conducted, citation issued and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 06:56 AM - It Cannot Be Edited


Created By: Melisa Rankin On 08/13/2024 at 04:57 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85075(b)
Health-Related Services
(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on an observation, the licensee did not comply with the section cited above in that medicaiton errors were found, where Lorazepam was noted as distributed, but it was still in the package, and medicaton needing to be destroyed was not on the destruction record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Facility will provide training for all staff in regards to medication management, medication record keeping, and ensuring all clients recieve their medication. A copy of the training sign in sheet showing all staff have completed the training will be submitted to licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


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