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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801528
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:14:07 PM


Document Has Been Signed on 04/10/2024 01:14 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:MOM'S PLACE 2FACILITY NUMBER:
565801528
ADMINISTRATOR:LAILA KULUNGUFACILITY TYPE:
740
ADDRESS:30 LA PATERA CT.TELEPHONE:
(805) 383-6855
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 4DATE:
04/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Laila KulunguTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management visit to address deficiencies observed during a pre-licensing visit conducted for a Change of Ownership (CHOW) application. Administrator was informed of the reason for today's visit. Entrance interview conducted.

During today's visit, a facility tour was conducted beginning at 10:48AM and LPA reviewed files beginning at 11:11AM. At 10:59AM, water temperature was tested in the hallway bathroom and measured at 124.5 degrees Fahrenheit. During the facility tour, LPA also noted Resident #1 (R1) to have full bedrails. Record review revealed that R1 is not on hospice and does not have orders for bedrails.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was advised that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
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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Document Has Been Signed on 04/10/2024 01:14 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: MOM'S PLACE 2
FACILITY NUMBER: 565801528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2024
Section Cited
CCR
87303(e)(2)

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87303 (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care... attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
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The facility staff turned down the water heater during today's visit. Water temperature was re-tested and was brought down to 120 degrees. Administrator will measure hot water temperatures for the following 2 days and update LPA on the temperatures to ensure consistent in-range water temperatures.
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Based on observation, the licensee did not comply with the above cited section, as water temperature was recorded in the shared resident bathroom at 10:59AM at 124.5 degrees Fahrenheit, which poses an immediate safety risk to residents in care.
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Type B
04/12/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports (a) (5) (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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During today's visit, Administrator contacted the home health company that provided R1's bed to make arrangements to change the full bed rails to half bed rails. Administrator is awaiting a call back from the scheduling department. Administrator will provide proof of removal of the full bed rails and installation
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Based on observation and record review, the licensee did not comply with the above cited section, as R1 was observed using full bed rails and is not on hospice, nor does R1 have a doctor's order for full bed rails, which poses a potential personal rights risk to residents in care.
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of half bed rails by POC due date.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
LIC809 (FAS) - (06/04)
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