425801769-8-28-2024-29-AS-EMIR-D8KVRG-20240828163955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801769
Report Date: 08/28/2024
Date Signed: 08/28/2024 04:40:25 PM

Document Has Been Signed on 08/28/2024 04:40 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:	PLEASANT CARE HOME		FACILITY NUMBER:	425801769
ADMINISTRATOR:	CHARMAINE ABATA		FACILITY TYPE:	740
ADDRESS:	1315 SAPPHIRE DRIVE		TELEPHONE:	(805) 934-4896
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 1	DATE:	08/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Angeles Pimentel, House Manager		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Miller arrived at 10:45 a.m. to conduct a one-year annual visit to the facility above. LPA met with Angeles Pimentel, house manager 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 4 resident bedrooms and 2 bathrooms. Facility currently occupies 1 residents and employs 6 full time staff, and 1 Administrator. LPA Miller was authorized to enter and inspect facility. The facility had a smoke and carbon monoxide detector that was tested and was working properly during visit. 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 and poisons are inaccessible to resident in care and are locked in cabinet in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on 5/10/2025. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory and 1 hospice.

Staffing: The facility currently employes 5 full time staff, and one Administrator. Staff files were reviewed. Administrator of record does not have a valid Administrator Certificate. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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 08/28/2024 04:40 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: PLEASANT CARE HOME	FACILITY NUMBER: 425801769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as there is no record of a valid Administrator Certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Administrator agrees to ensure that a valid Administrator's Certificate is on file by the POC date and/or update the Administrator of record.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above, as there were significant changes in resident's mobility and cognitive decline which poses/posed a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 09/16/2024
	Plan of Correction
1 2 3 4	Administrator agrees to update the appraisal needs and service plan as well as update the resident’s medical assessment by the POC date.

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: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

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: PLEASANT CARE HOME	FACILITY NUMBER: 425801769
	VISIT DATE: 08/28/2024

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Personnel Records & Training: The facility keeps confidential files for each staff member. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Staff have annual training completed for some subjects/topics and hours for 2024

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 1 resident file for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. There were significant changes in resident’s cognitive ability and physical mobility that will be addressed in a re-appraisal and an updated Physician’s Report as agreed to by House Manager.

Food Service: The facility has 2-day perishables and 7-day non-perishables and plenty 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. Cleaning solutions and equipment are stored separately from food supplies.

Disaster Preparedness: The current emergency disaster forms were not posted, but House Manager was advised to do so immediately. 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.

Exit interview conducted, citations were issues and copy of report and appeal rights were provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024

LIC809 (FAS) - (06/04)

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