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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801300
Report Date: 10/25/2022
Date Signed: 10/26/2022 08:23:38 AM


Document Has Been Signed on 10/26/2022 08:23 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:HOME SWEET HOME CAREFACILITY NUMBER:
565801300
ADMINISTRATOR:GLORIA P. VALENCIAFACILITY TYPE:
740
ADDRESS:7520 VAN BUREN STREETTELEPHONE:
(805) 659-4427
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:34 PM
MET WITH:Rosario GonzalesTIME COMPLETED:
09:35 PM
NARRATIVE
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During the course of investigating complaint number 29-AS-20221019154835, Licensing Program Analysts (LPAs) Teresa Camara and Angel Ascencio observed the following deficiencies:

Medication cabinet located in the kitchen/dining room area was left unlocked.

Laundry detergent was left out in the laundry area, unsecured.

Room deodorizers (Glade) and Lysol were left unlocked in the bathrooms.

Flies were observed throughout the facility, including in the kitchen and dining room.

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: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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Document Has Been Signed on 10/26/2022 08:23 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: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2022
Section Cited

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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.
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This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above as laundry detergent, room deodorizers, Lysol and medications were left unlocked which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/01/2022
Section Cited

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87555 General Food Service Requirements(b) The following food service requirements shall apply:(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement was not met as evidenced by:
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Based on interviews and observation, the licensee did not comply with the section cited above as flies were observed throughout the facility, including in the kitchen and dining room, which poses a potential health, safety or personal rights risk to persons in care.
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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: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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