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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801142
Report Date: 10/21/2022
Date Signed: 10/24/2022 08:30:25 AM


Document Has Been Signed on 10/24/2022 08:30 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:CHRISTIAN'S HOME FOR THE ELDERLYFACILITY NUMBER:
565801142
ADMINISTRATOR:MARIA C. CARTERFACILITY TYPE:
740
ADDRESS:3066 SCHOOL STREETTELEPHONE:
(805) 526-4715
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 2DATE:
10/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria CarterTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Maria Carter and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers appeared to be fully charged. The carbon monoxide and smoke alarms were tested and appeared to be functioning properly.

KITCHEN: The appliances appeared to be operational. The facility has a sufficient supply of perishable and non-perishable food. LPA observed knives in an unlocked drawer. LPA observed dish soap on the sink, as well as dish soap, bleach and pesticides in an unlocked cabinet under the sink.

BEDROOMS: Bedrooms appeared appropriately furnished, clean and with sufficient lighting.

RESTROOMS: The bathrooms appeared clean and in operating condition.

COMMON SPACES: The living room, dining room and family room appeared appropriately furnished. There were a few boxes in the family room as the licensee is preparing to remodel this facility. In addition, there was recently a pipe leak in the living room and repairs to the drywall and flooring are pending insurance inspection. Steps have been taken to avoid any trip hazards. Medications and records are stored in a locked file cabinet in the family room.

(continued on 809-C)

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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 5


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: CHRISTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801142
VISIT DATE: 10/21/2022
NARRATIVE
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(continued from 809)

LPA observed three adult family members living at this facility: occupant 1 (O1) is the administrator’s spouse, occupant 2 (O2) is the administrator’s son, and occupant 3 (O3) is the administrator’s brother-in-law. O3 is visiting temporarily to assist with some of the remodeling projects at the property. None of these adult family members provide care to residents, however since they are residing at the facility they all must have criminal record clearances and associations to the facility, which they do not. The administrator stated she will immediately have these family members fingerprint cleared and they will stay elsewhere until their clearance and association is confirmed.

The administrator stated she intends to issue eviction notices to the two residents currently residing at the facility. She has already notified their families verbally and will assist them with finding other options. Once these two residents are relocated the administrator intends on closing the facility.

OUTDOOR SPACES: The backyard has shaded areas and seating on the patio. However, there were many tools and construction items observed on the side of the house which were accessible. The side gate was not self-latching.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. The administrator was the only staff observed at the facility and she was not wearing a mask. LPA informed the administrator that all staff and visitors must wear masks. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted. Today's reports and appeal rights were discussed. A copy of the report was emailed to the Administrator.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/24/2022 08:30 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: CHRISTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observation, the licensee did not comply with the section cited above as three individuals (O1, O2, O3) have been residing at the facility without criminal record clearances or faciltiy association, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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The Administrator has agreed to do the following:
Have adult family members fingerprint cleared and associated to the facility. These individuals may not return until it is done.

Zero tolerance violation; immediate civil penalty assessed of $1500
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observatio, the licensee did not comply with the section cited above as LPA observed knives stored in an unlocked kitchen drawer and many construction tools stored accessible on the side of the house which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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The administrator has agreed to do the following:
Ensure residents do not access backyard until all construction items have been secured. Administrator locked the knife drawer in the kitchen during LPA's visit. Administrator will provide CCL with photos of the back yard showing how all construction tools have been secured on or before 10/28/2022.

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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 10/24/2022 08:30 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: CHRISTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

(2) 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:
Deficient Practice Statement
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Based on interviews and observation, the licensee did not comply with the section cited above as dishsoap, bleach and pesticaides were stored in an unlocked cabinet under the sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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The administrator locked the cabinet where the toxic substances were stored during LPA's visit. Plan of Correction 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/24/2022 08:30 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: CHRISTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
87705 Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and observation, the licensee did not comply with the section cited above as the side gate does not freely open and is not self latching, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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The Administrator has agreed to do the following:
Have the gate repaired so it opens and self-latches. A photo of the repaired gate must be sent to CCL on or before 10/28/2022.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5