565801532-10-21-2024-29-AS-MARO-DA9UGB-20241021153404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801532
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:34:12 PM

Document Has Been Signed on 10/21/2024 03:34 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:	NORMA J'S HOME FOR THE ELDERLY, THE		FACILITY NUMBER:	565801532
ADMINISTRATOR:	LORETTA LOUISE TIEDE		FACILITY TYPE:	740
ADDRESS:	142 W. COLUMBIA ROAD		TELEPHONE:	(818) 422-7667
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Robin Douglas - Facility Manager		TIME COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:50 a.m. Upon arrival, there were two (2) staff and six (6) residents present. The LPA was greeted by facility staff who contacted the Administrator via telephone. At this time, the reason for the visit was explained. The facility manager, Robin Douglas arrived at 11:00 a.m. The Administrator, Loretta Tiede arrived during the inspection. Entrance interview conducted.

The LPA along with the facility manager 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.

KITCHEN: The LPA inspected the kitchen/food service area at 11:20 a.m. Knives and sharps were observed in a locked drawer. Cleaning supplies were observed locked under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 127.9 degrees Fahrenheit at 11:24 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:37 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 10/15/2024. The LPA observed required postings throughout the common space. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 10/06/2024. Activities were observed in the common areas. There is a working telephone on premises. There is a laundry closet with a washer and dryer. Laundry detergent was observed in a locked cabinet above the washer and dryer. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 10/21/2024

NARRATIVE

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Report Continued from LIC 809...

RESTROOMS: There are three (3) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 109 degrees Fahrenheit at 11:10 a.m.; the second bathroom measured at 115.7 degrees Fahrenheit at 11:17 a.m.; and the third bathroom measured 134.2 degrees Fahrenheit at 11:31 a.m. Staff adjusted water temperature at the time of the inspection.

BEDDROOMS: There are 6 (six) total bedrooms in the facility; one (1) is designated as a shared room, four (4) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage was locked and inaccessible to residents at the time of the visit. There is an additional refrigerator with perishable food, in good condition. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of any obstructions. There is a side gate that is single latched. LPA observed a gated pool in the backyard that was locked and inaccessible at the time of the visit.

RECORDS: LPA reviewed Resident Records at 12:04 p.m. and Personnel Records at 12:46 p.m.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

Four (4) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
	VISIT DATE: 10/21/2024

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Report Continued from LIC 809C...

MEDICATIONS: Medications review began at approximately 1:50 p.m. The medications are locked in a cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications are labeled and checked for expiration dates. Medications appeared to be given as prescribed at the time of the visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2024 03:34 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: NORMA J'S HOME FOR THE ELDERLY, THE	FACILITY NUMBER: 565801532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as the hot water temperature in resident bathrooms ranged between 109 and 134.2 degress Fahrenheit, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2024
	Plan of Correction
1 2 3 4	Staff had water temperature adjusted and corrected at the time of the visit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC809 (FAS) - (06/04)

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