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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801300
Report Date: 07/17/2023
Date Signed: 07/17/2023 05:04:55 PM


Document Has Been Signed on 07/17/2023 05:04 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
WOODLAND HILLS NORTH, 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: 4DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gloria Valencia TIME COMPLETED:
05:10 PM
NARRATIVE
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At 09:00 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. Two (2) staff and four (4) residents were present when the LPA arrived. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Gloria Valencia arrived shortly after.

At 09:10 a.m. the LPA conducted a tour of the physical plant with Administrator Gloria Valencia to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a one-story residence that consists of six (6) resident rooms (two of which are unoccupied), two (2) staff rooms and two and a half (2.5) bathrooms. The LPA observed two fire extinguishers throughout the facility, one was last serviced January 2021, and the other did not have a service tag. Administrator provided receipt of the second fire extinguisher ordered on 03/10/2022. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. The LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: During the facility tour at 9:40 a.m., the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are available for residents. At 9:42 a.m., the LPA observed two (2) 11’’ gas lighters in an unlocked drawer, accessible to residents in care.
Bedrooms: During today’s visit, the LPA observed all of the resident rooms. The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 9:21 a.m., the LPA observed Kids’ Pain & Fever Acetaminophen medicine on top of a drawer in room 5, which was unlocked and accessible to residents in care.
Report will continue on LIC809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 05:04 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review the licensee did not comply with the section cited above as one (1) out of four (4) residents (R2) are diagnosed as bedridden and the facility does not have a bedridden fire clearance which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/24/2023
Plan of Correction
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In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected. The Administrator agrees to call the appropiate agency, (fire marshall) today and start the process to get the appropiate bedridden fire clearance and submit proof no later than 7/24/2023, and submit proof of fire clearance to CCL.
Type A
Section Cited
CCR
87705(f)(1)
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 observation, the licensee did not comply with the section cited above as the LPA observed Kids’ Pain & Fever Acetaminophen medicine, two (2) gas lighters, five (5) razors, one (1) pair of scissors, one (1) Awesome Cleaner with Bleach spray bottle, one (1) Lysol disinfectant spray and additional cleaning supplies accessible to residents which poses an immediate health, and safety risk to persons in care.
POC Due Date: 07/17/2023
Plan of Correction
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Upon observation, staff locked away all items that can constitute a danger to the residents. Administrator agrees, all staff will receive training on all items that should be inaccessible to residents with dementia and send proof to CCL by 7/26/2023.
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: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 07/17/2023 05:04 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 in one out of five residents (R1) did not have an annual reappraisal on file, and has a diagnosis of dementia which poses a potential health and safety risk to persons in care.
POC Due Date: 07/26/2023
Plan of Correction
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Administrator agrees to complete an annual Apraissal & Needs and services plan for R1 and submit proof to CCL no later than the end of day on the POC due date.
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: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300
VISIT DATE: 07/17/2023
NARRATIVE
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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 9:17 a.m., the LPA observed five (5) razors, one (1) pair of scissors, one (1) Awesome Cleaner with Bleach spray bottle, one (1) Lysol disinfectant spray and additional cleaning supplies in one of the bathrooms drawers and cabinet, accessible to residents. Upon observation, staff took all items out of the restroom, and stated they had lost the key to the cabinet lock. Hot water measured 114.9 degrees Fahrenheit, within the required limit of 105-120 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 70 degrees. At 9:53 a.m., the LPA observed the screen door in the dining room leading to the backyard to have a rip on the right side under the handle bar.



Surrounding Grounds (Outdoors): There was a shaded area with furniture for outdoor use. There are no bodies of water on the premises. The LPA observed outdoor furniture to be unkempt with spider webs, rusty, and covered in dust.

Infection Control: The community's policies and procedures pertaining to infection control were adequate.

Record Review: At 12:10 p.m. a review of facility files was initiated. The LPA reviewed four (4) of four (4) resident files. Out of the four files reviewed, the LPA identified that one out of four residents (R1) requires an updated Appraisal & Needs and Service Plan report, due to the diagnosis of dementia. The LPA also identified that one out the four residents (R2) is bedridden, and the facility does not have bedridden fire clearance for R2. The LPA advised the Administrator to review R1’s file and to get the appropriate bedridden clearance as soon as possible for R2. Otherwise, all resident records were in order.

Due to time constraints the LPA will return to complete the annual at a later date.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/17/2023 05:04 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: HOME SWEET HOME CARE
FACILITY NUMBER: 565801300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 as the LPA observed two fire extinguishers at the facility, one last serviced January 2021, and the other did not have a service tag. Administrator provided receipt of the second fire extinguisher ordered on 03/10/2022 which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/17/2023
Plan of Correction
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 In accordance with the California Health and Safety Code Section 1568.0822(c), you are hereby notified that an immediate $500 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected. Administrator went to the store and bought a new fire extinghiser during the visit.
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: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6