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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850004
Report Date: 12/28/2021
Date Signed: 12/28/2021 07:48:59 PM

Document Has Been Signed on 12/28/2021 07:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:YOKAM'S RCFE #1FACILITY NUMBER:
425850004
ADMINISTRATOR:KAMTO, YOLANDE KONGUEP T.FACILITY TYPE:
740
ADDRESS:958 E TUNNELL STTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 4DATE:
12/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Cheryll AteTIME COMPLETED:
04:30 PM
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On 12/28/21 Licensing Program Analysts (LPA) Diaz conducted a Case Management visit. LPA met with Administrator Cheryll Ate.

While touring the facility, LPA observed a resident sitting in the family room watching television. The administrator confirmed that two residents in the facility are diagnosed with dementia. LPA noticed unlocked cabinets in the garage with numerous cleaning chemicals and exposed engine oil laying on a counter top. LPA asked the Administrator to the lock the laundry room door that leads to the garage and the administrator complied. LPA also found Clorox sprays and cleaning supplies in unlocked cabinets in the kitchen. During the end of the inspection LPA checked if the door to the garage remained locked, but LPA found the door unlocked again. Numerous hazardous cleaning chemicals were accessible to the residents.

Report reviewed and printed, exit interview conducted, deficiencies cited (on LIC809-D).
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/28/2021 07:48 PM - It Cannot Be Edited


Created By: Arien Diaz On 12/28/2021 at 04:09 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: YOKAM'S RCFE #1
FACILITY NUMBER: 425850004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2021
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed items in an inaccessible location during facility visit. Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(2) to CCL by 12/31/21.
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Based on LPA's observations and the licensee did not comply with the section cited above as over-the-counter medication, nutritional supplements and toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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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:Arien Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021


LIC809 (FAS) - (06/04)
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