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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801142
Report Date: 11/21/2023
Date Signed: 01/23/2024 11:25:58 AM


Document Has Been Signed on 01/23/2024 11:25 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:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria CarterTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual. The LPA met with staff Soliman Lamdrado and Licensee Maria Carter. Reason for the visit was explained. Upon arrival LPA and staff 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. LPA was informed by Licensee and staff that currently the facility is being renovated. Following was observed:

At approximately 11:21am, LPA and staff toured the kitchen area: sufficient supply of perishable and non-perishable food items observed. The cabinet under the sink was observed unlocked with comet, dish soap, bleach and pesticides accessible to others. Medications observed accessible in a pill box in the kitchen/dining area on the desk. Canned and dried food supply in boxes stored in the common space (dining/living room). In the family TV room the dry wall behind the sofa was cut open to fix pipes; dry wall near the front entrance was cut open with electrical wiring exposed. The facility has four (4) bedrooms which are all cleared for resident rooms. LPA observed the two vacant resident rooms are currently being used by the licensee's family and staff. The other two (2) rooms are occupied by residents. The rooms appeared with appropriately furnished however the two (2) resident rooms occupied by residents smelled of strong urine odor. The room occupied by staff observed unlock during LPA's visit with several medications and vitamins accessible. The fire extinguishers was observed due for service. Last serviced on 10/27/2022.

12pm -The carbon monoxide and smoke alarms tested by staff did not work during visit. Staff stated since they are remodeling the smoke detectors have not been functioning properly.

The facility has two (2) bathrooms: One bathroom is located in the master bedroom were the licensee and her spouse are currently staying. This bathroom observed to be full of hygiene and cleaning products accessible to others (master bedroom door was unlocked during LPA's visit). The other bathroom located in the hall way also observed with hygiene supplies and hair spray accessible. Dry-wall in the bathroom near the toilet was opened. Hot water temperature tested in the hallway bathroom measured at 110.4*F.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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: CHRISTIAN'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801142
VISIT DATE: 11/21/2023
NARRATIVE
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LPA observed many tools and construction items on the side of the house which were accessible during the visit. Licensee stated that the backyard is currently being cleaned by her spouse and son.

At approximately 1pm-3pm Resident and staff files were reviewed. Resident #1 and Resident #2's files did not have an updated appraisal/needs and services plans. Licensee/Administrator file reviewed revealed that Ms. Carter's administrator certificate expired 10/1/2022. She has not submitted required documents for renewal. Staff #1 also did not have a valid administrator certificate. No training for staff since the pandemic 2019. Staff #1 did have a valid first aid certification, health screening documentation, employee rights and criminal record clearance.

Ms. Carter stated to LPA that she plans to issue 30 day notice to the two residents families since it is too much for her right now with the remodeling and to keep up with all the regulations. LPA informed Ms. Carter to submit copy of the 30 day notice and also if she decides to close the facility she needs to submit a letter to the department and surrender her facility license for this property.

Due to time constraints this annual visit will be continued to another date.

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



Exit interview conducted. Today's reports and appeal rights were discussed and copy was provided to Licensee.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:25 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Staff #1 and Licensee who live in the facility have not continued with required training to assist residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Ms. Carter stated that since she is remodeling the facility and everything is overwhelming right now she will issue a 30 day notice for the two residents; in the meantime she will provide contact information for the individual that holds a valid administrator certificate to oversee the facility. Submit contact information and schedule (LIC500) and required docmentation necessary for change administraor.
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. all smoke detectors in resident rooms were not operable; the only carbon monoxide located in the hallway was also non operable during todays visit. This poses an immediate health and safety risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Ms. Carter stated that she will replace the smoke detectors and the carbon monoxide in the hallway today. Submit proof of smoke and carbon monoxide detectors installed (photo) and a self certification letter that all were tested and are operable by 11/22/23.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:25 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hygiene and cleaning supplies observed in the bathrooms and under kitchen sink cabinet accessible to all. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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Kitchen cabinet was locked during visit and other hygiene products accessible in the bathrooms were moved to locked cabinet during todays visit.
Section Cited
Other Provisions
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:25 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)
Admiistrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Ms. Carter's administrator certificate expired 10/1/2022. Ms. Carter did not renew her certificate and continued to operate facility without an administrator. This poses an immediate health and safety risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Ms. Carter stated she will obtain assistance from a certified administrator to oversee facility operation. Submit documents for change of administrator by 11/22/2023. 1) Board of resultion appointing new administrator; 2) ID copy; 3) LIC501; 4)Administrator certificate copy; 5) health screening; and 6) LIC508;
Type A
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

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 #1 and administrator did not have valid proof of annual medication training. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Ms. Carter shall coordinate with appropriate indiviual to conduct annual medication training for staff #1. In the meantime Ms. Carter agreed to schedule appropriate staff with valid medication training to assist resident with medication until residents are relocated.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:25 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows: 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Resident rooms smelled of strong urine odor. This poses a potential health and safety rights risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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Resident in the room were recently changed according to staff however the room still smelled of strong urine odor at the time of inspection. Ms. Carter will ensure that resident rooms are clean and odor free at all times. Provide written statement and cleaning schedule for resident rooms.
Section Cited
Maintenance and Operation
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:26 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 as two (2) out of two (2) resident files reviewed revealed last meeting with residents representitive was in 2019/2020. This poses a potential health and safety risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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Licensee will provide plan of correction before 11/28/2023.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


Document Has Been Signed on 01/23/2024 11:26 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety and personal rights risk to persons in care. No poster for, Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints,
POC Due Date: 11/28/2023
Plan of Correction
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Licensee agreed to obtain and post the departments complaint poster. Submit photo of the complaint poster once posted up on the wall. Submit plan of correction by 11/28/2023.

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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 11:26 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: 11/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview with licensee, the licensee did not comply with the section cited above. The licensee is currently renovating and occuping space indoors common area space and outdoors for which doesn't allow appropriate space for residents use. This poses a potential health and safety risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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3
4
Licensee stated she plans provide 30 day notice to the residents and in the mean time will clear out common area space and outdoor space for residents use. Provide plan of correction to LPA by 11/28/2023.
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed food stored in containers with no expiration date and no hand written date of when food items in these containers were made. This which poses a potential health and safety risk to persons in care.
POC Due Date: 11/28/2023
Plan of Correction
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2
3
4
Licensee agreed to have staff go through the refrigerator and remove any items that are not dated or do not have expiration dates. Provide in-service to staff. Provide plan of correction to LPA by 11/28/2023.
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: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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