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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800984
Report Date: 01/27/2024
Date Signed: 01/27/2024 11:39:11 AM

Document Has Been Signed on 01/27/2024 11:39 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:PHYLLIS FAMILY HOMEFACILITY NUMBER:
565800984
ADMINISTRATOR:LORRAINE MEDINAFACILITY TYPE:
735
ADDRESS:2445 EAST PHYLLIS STREETTELEPHONE:
(805) 581-0751
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Lorraine MembrenoTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 12/16/2022. When the LPA arrived, there was one (1) staff and two (2) clients present. The LPA met with staff Edith Diaz, and at this time the reason for the visit was explained. The Administrator, Lorraine Membreno arrived during the inspection. Entrance interview conducted.

At 8:06 a.m., the LPA along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The kitchen area was observed at 8:10 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The knives and sharps are stored in a locked drawer inaccessible to clients in care. The water temperature was measured in the kitchen sink at 139.6 degrees Fahrenheit at 8:15 a.m.

Common areas: Living and dining room furniture were observed to be in good condition. At 8:25 a.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was last charged and serviced on 10/15/2023. Emergency exits and passageways were observed free of obstruction.

(Report Continued on LIC 809C..)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984
VISIT DATE: 01/27/2024
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(Report Continued from LIC 809...)

Garage/Outdoor: The washer and dryer are in the garage. Cleaning supplies and disinfectants are stored in a locked cabinet inaccessible to clients. There is one (1) additional refrigerator and freezer with perishable items in good condition inside the garage. The LPA observed an adequate supply of emergency food and water. The backyard has a covered outdoor area equipped with furniture for client use. There are two (2) side gates with clear passageways in case of an emergency. No bodies of water noted at the time of visit.

Restrooms: There are two (2) client restrooms which were observed clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels; bath towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; the first bathroom measured at 131.3 degrees Fahrenheit at 8:09 a.m.; and the second bathroom was measured at 131.7 degrees Fahrenheit at 8:19 a.m. The staff adjusted the water temperature at the time of the visit.

Bedrooms: There four (4) client bedrooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed. Facility has a sufficient supply of extra linens and towels for client use.

Records: The LPA reviewed facility files at 8:47 a.m. Four (4) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

At 9:20 a.m., records review revealed that one (1) out of four (4) clients does not have a needs and service plan on file. The Administrator completed the client’s needs and service plan at the time of the visit.

The LPA reviewed three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/cpr certification, and yearly training.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984
VISIT DATE: 01/27/2024
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(Report Continued from LIC 809C...)

At 9:42 a.m., records review revealed that one (1) out of three (3) staff had an expired 1st aid/cpr. The Administrator and staff stated that training was completed recently and will provide proof to LPA in the next 24 hours.

The facility is vendored by Tri-Counties Regional Center (TCRC). The last disaster drill was conducted on 12/12/2023.

Medications: Medications review began at approximately 10:25 a.m.; medications are centrally stored in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2024 11:39 AM - It Cannot Be Edited


Created By: Martha Arroyo On 01/27/2024 at 11:23 AM
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: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as the hot water temperature in client’s restrooms measured between 131.3 and 131.7 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2024
Plan of Correction
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Staff adjusted water temperature at the time of the visit.

POC has been met.
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 Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
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