565801056-9-22-2023-29-AS-MARO-CVX39L-20230922180318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801056
Report Date: 09/22/2023
Date Signed: 09/22/2023 06:03:27 PM

Document Has Been Signed on 09/22/2023 06:03 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:	MILLENNIUM CARE II		FACILITY NUMBER:	565801056
ADMINISTRATOR:	IRIS VAN KRALINGEN		FACILITY TYPE:	740
ADDRESS:	5694 FEARING STREET		TELEPHONE:	(805) 527-7798
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Iris Van Kralingen		TIME COMPLETED:	06:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 2:15 p.m. The last annual conducted at this facility was on 09/01/2022. Upon arrival, the LPA met with Administrator, Iris Kranlingen and the reason for the visit was explained. There were three staff and five residents present. Entrance interview conducted.

The LPAs 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 LPA began the inspection in the kitchen/food service area at 2:23 p.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. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The LPA observed the knives and sharps stored in a locked drawer. Cleaning supplies and disinfectants are stored under the kitchen sink inaccessible to residents. At 2:27 p.m., the hot water temperature was measured in the kitchen at 116.2 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed two residents watching television in the living room. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 3/16/2023. The LPAs observed required postings throughout the common space. All doors were observed with functioning auditory alarms at the time of the visit.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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: MILLENNIUM CARE II	FACILITY NUMBER: 565801056
	VISIT DATE: 09/22/2023

NARRATIVE

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(Report Continued from LIC 809...)

GARAGE/BACKYARD: There is a separate laundry room, which is kept locked. The garage is accessible through the laundry room. There was emergency food and water in the garage which was observed to be in good condition. Cleaning supplies and toxins were observed locked and inaccessible to residents in care. The facility has at least a 30-day supply of Personal Protection Equipment (PPE). The backyard has a covered outdoor area equipped with furniture for resident use. The property is completely fenced with a self-latching mechanism. There is a completely fenced swimming pool, which is kept locked and inaccessible to residents.

BEDROOMS: There are three (3) resident bedroom. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises. There was a linen cabinet in the hallway with extra towels and linens.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathroom; the first bathroom measured at 115.7 degrees Fahrenheit at 2:31 p.m.; and the second bathroom was measured at 115.5 degrees Fahrenheit at 2:33 p.m.

At 2:31 p.m., the LPA observed the common hallway restroom to have accessible items to all residents which included toothpaste, mouthwash, lotion, shampoo, and conditioner. The Administrator had all personal hygiene items locked immediately.

RECORDS: Records review began at 2:47 p.m.; five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

At 3:15 p.m., record review of Resident #1’s (R1’s) physician’s report (LIC 602A) dated 04/18/2023 and Resident’s #2 (R2’s) physician’s report dated 07/11/2023 revealed R1 and R2 are at risk if allowed direct access to personal grooming and hygiene items.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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: MILLENNIUM CARE II	FACILITY NUMBER: 565801056
	VISIT DATE: 09/22/2023

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(Report Continued from LIC 809C...)

MEDICATIONS: Medications review began at 4:45 p.m.; medications are centrally stored and locked in a cabinet adjacent to the living room. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

The LPA conducted interviews with three staff members between 5:00 p.m. and 5:18 p.m.

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 deficiency may result in civil penalties.

Exit interview conducted. The report was reviewed, and a copy of the appeal rights and report were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/22/2023 06:03 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MILLENNIUM CARE II	FACILITY NUMBER: 565801056
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(g)

Care of Persons with Dementia

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as R! and R2 are not allowed to have access to personal grooming and hygiene item accessible per LIC 602A, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	The Administrator locked all items immediately at the time of the visit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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