565801508-11-14-2024-29-AS-VCOY-DAZUWD-20241114145633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801508
Report Date: 11/14/2024
Date Signed: 11/14/2024 02:57:54 PM

Document Has Been Signed on 11/14/2024 02:57 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EDNA'S RESIDENTIAL CARE I		FACILITY NUMBER:	565801508
ADMINISTRATOR/ DIRECTOR:	EDNA DANGIAPO		FACILITY TYPE:	740
ADDRESS:	3868 SENAN STREET		TELEPHONE:	(805) 278-2035
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Edna Dangiapo		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:20 A.M. When the LPA arrived, there were three (3) staff members and six (6) residents present. The LPA was greeted by Caregiver, Nikki Villanueva. LPA informed the reason for the visit. Caregiver contacted the Administrator by phone, Edna Dangiapo. At 9:55 A.M. Administrator arrived at the facility. Entrance Interview conducted.

Beginning at 9:57 A.M., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Smoke detector was tested at 10:35 A.M. and carbon monoxide detector was tested at 10:10 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 07/08/2024.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

Continued on LIC 809-C

Desaree Perera	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA'S RESIDENTIAL CARE I	FACILITY NUMBER: 565801508
	VISIT DATE: 11/14/2024

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Continued from LIC 809

BEDROOMS: There are 6 (six) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms and 1 (one) is designated as a staff room. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff room was observed to be locked.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility, both of which are common restrooms for shared resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Hot water temperature was measured and was within the required range.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Medication and resident files were observed to be locked inside kitchen cabinets next to the fridge at the time of the visit. At 10:15 A.M. hot water measured at 119.4 degrees Fahrenheit.

GARAGE/LAUNDRY ROOM: Adjacent to the kitchen is a garage. LPA observed a washer and dryer. Garage remains unlocked, but contains a locked cabinet that contains cleaning supplies, personal grooming items, as well as knives and sharps. Garage also contains extra food, emergency food and water as well as storage.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. No bodies of water were observed at the time of the visit. All exits and passageways were observed to be free of hazards. Facility has two side gates; both were observed to be self-latching and closing with clear passageways for emergency exit use.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA'S RESIDENTIAL CARE I	FACILITY NUMBER: 565801508
	VISIT DATE: 11/14/2024

NARRATIVE

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Continued from LIC 809-C

RECORD REVIEW: Between 11:00 A.M. and 12:12 P.M. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Six (6) resident records reviewed were complete and contained all required documents. LPA observed that the Administrator has been using the Resident Appraisal (LIC603A) form in place of the required Appraisal/Needs and Service Plan (LIC625). Licensee stated that the LIC603A has been utilized for several years and was unaware of the requirement for a LIC625 form. The LPA emailed the Administrator a copy of the LIC625 and explained that LIC 625 shall be completed annually or whenever there is a change in the resident’s condition. Four (4) staff files including the Administrators were reviewed. All files were complete and contained all required documents. At 9:20 A.M. LPA knocked on the door to conduct today’s annual visit. Staff #1 (S1) opened the door and notified Staff #2 (S2) that LPA was present. After LPA began the visit, S1 was no longer in the area. When the Administrator arrived, LPA inquired about S1. The Administrator stated that S1 is S2’s spouse. Additionally, Administrator informed LPA that S1 is not currently an employee of the facility, however, S1 has been helping around the facility informally to determine if S1 is a good fit for a potential caregiver role. LPA asked the Administrator if S1 has fingerprint clearance. The Administrator responded that S1 does not currently have fingerprint clearance, as they are not yet an employee. A review of the facility records and interviews confirmed that S1 does not have an employee file. Additionally, a check of the Guardian system revealed that S1 is not associated to the facility and does not have a fingerprint clearance on file. LPA reminded Administrator that per regulation any person who provides client assistance shall be deemed to meet the criminal record clearance requirements. Furthermore, LPA reiterated Administrator that all staff members shall complete fingerprinting, undergo a background check, and be officially associated with the facility before assisting residents. S1 left the facility during today’s visit.

MEDICATION REVIEW: At 12:50 P.M. medications for 6 (six) residents were observed. All residents' medications were observed to be maintained and administered in compliance with regulation.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA'S RESIDENTIAL CARE I	FACILITY NUMBER: 565801508
	VISIT DATE: 11/14/2024

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Continued from LIC 809-C

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) residents/family members.

During today's visit, LPA gathered the following Personnel report (LIC 500), Resident Roster, a copy of the facility's liability insurance. Emergency disaster drills are conducted quarterly, with the last drill documented on 11/01/2024.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/14/2024 02:57 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EDNA'S RESIDENTIAL CARE I	FACILITY NUMBER: 565801508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Licensing

(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited aboveby having S1 is not associated to the facility and does not have a fingerprint clearance on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	S1 left the facility during today’s visit. POC cleared.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Desaree Perera	TELEPHONE: (818) 596-4347
Valeria Conway	TELEPHONE: (818) 454-0485
	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC809 (FAS) - (06/04)

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