565801300-6-24-2022-29-AS-JROS-CFPVA3-20220624161517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801300
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:19:36 PM

Document Has Been Signed on 06/24/2022 04:19 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:	HOME SWEET HOME CARE		FACILITY NUMBER:	565801300
ADMINISTRATOR:	GLORIA P. VALENCIA		FACILITY TYPE:	740
ADDRESS:	7520 VAN BUREN STREET		TELEPHONE:	8056594427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 6	DATE:	06/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Gloria Valencia		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Gloria Valencia. During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted hot water temperature (read at 112.3 degrees F.) in resident bathroom. Grab bars were present in the bathrooms. Hygiene items are being provided. LPA observed a sufficient supply of perishable and nonperishable food. LPA observed appropriate lighting in the facility. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detectors were tested and were operable. Disinfectants and cleaning supplies were in a locked garage. Medications were centrally stored and are kept in a locked kitchen cabinet. Outdoor area toured- passageways are free of obstruction. During facility tour at 2:31 pm with Administrator LPA observed resident #1 (R1)'s albuterol sulfate solution, ear drops and Polident denture cleanser in R1's bedroom accessible to residents. During facility tour at 2:33 pm with Administrator LPA observed 2 bottles of wite-out correction fluid in a kitchen drawer accessible to residents. During facility tour at 2:34 pm with Administrator LPA observed dish soap on kitchen sink accessible to residents. Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
	VISIT DATE: 06/24/2022

NARRATIVE

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During facility tour at 2:39 pm with Administrator LPA observed fiber therapy in laundry room accessible to residents.

During facility tour starting at 2:40 pm with Administrator LPA observed Polident denture cleanser and disinfectant spray in staff bathroom accessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, todays reports and appeals rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/24/2022 04:19 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: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation and record review, the licensee did not comply with the section cited above as R1's albuterol sulfate solution was observed accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Staff locked R1's albuterol sulfate solution in the locked medication cabinet during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87465(h)(2) to CCL by 7/4/22.

Type A

Section Cited

CCR

87705(f)(2)

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
1 2 3 4	Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medication and toxic substances were accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 06/24/2022
	Plan of Correction
1 2 3 4	Staff placed items in an inaccessible location during facility visit. Administrator stated that they will provide documentation of staff inservice regarding regulation 87705(f)(2) to CCL by 7/4/22.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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