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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800421
Report Date: 01/17/2024
Date Signed: 01/23/2024 09:17:25 AM


Document Has Been Signed on 01/23/2024 09:17 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:MILLENIUM CAREFACILITY NUMBER:
565800421
ADMINISTRATOR:MAYA X. DAVIDSZFACILITY TYPE:
740
ADDRESS:1555 HILGARD AVENUETELEPHONE:
(805) 526-4440
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Iris Van Kralingen, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit. Upon arrival LPA met with Administrator Iris Van Kralingen and (2) staff. Reason for visit was stated.
Between approximately 2:15pm-2:40pm, a tour of the physical plant was conducted with Administrator. All required postings observed posted on the wall in the entry area. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. Smoke/carbon monoxide detectors were tested and found to be operable during visit. Fire extinguishers appear to be fully charged last serviced 03/06/2023. There are five (5) bedrooms total. One (1) bedroom is designated for staff use; two (2) shared and two (2) private bedrooms for resident use. The facility maintains a comfortable indoor temperature. Bedrooms were furnished appropriately to ensure the comfort and safety of the residents. Facility has two bathrooms for resident use with appropriate grab bars and nonskid mats. There is a sufficient supply of linens, and towels and toiletries. Auditory alarms on all exits were tested and function properly. Common areas including the living and dining areas observed for functionality and appear sufficient. Kitchen area: LPA observed sharps and chemicals in the kitchen to be locked and inaccessible to residents. Facility maintains two (2) day perishable and seven (7) day nonperishable food supply. LPA observed the backyard has a covered patio area with table and chairs for resident use. There is a self-latching gate on one side of the facility. There are no bodies of water or fire arms/ammunition on the premises. The last disaster drill was conducted on . (2:45pm) Resident files were reviewed for updated Needs and Services plans, medical assessments, admission agreements, and all other pertinent documents in their files. (3:30pm) Staff records were reviewed and noted to be complete for first aid certification, health screening documentation, employee rights and criminal record clearance. Staff annual training hours were not complete. Medications are kept in a locked cabinet in the kitchen area. Centrally Stored Medication logs observed. Physician’s orders observed on file for residents medication. First aid kit was observed complete.

The following deficiency observed (See LIC 809-D) and cited from the Title 22 California Code of Regulations. Exit interview held. Copy provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 01/23/2024 09:17 AM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: MILLENIUM CARE
FACILITY NUMBER: 565800421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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. Staff records reviewed for 2 out 2 staff did not meet the training hours required. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
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Administrator agreed to provide proof of required training hours and subjects for staff 1 and 2 by 01/24/2024.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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