565801892-12-6-2023-29-AS-TCAA-CY9VR7-20231206153927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801892
Report Date: 12/06/2023
Date Signed: 12/06/2023 03:40:38 PM

Document Has Been Signed on 12/06/2023 03:40 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:	FILLMORE COUNTRY CLUB		FACILITY NUMBER:	565801892
ADMINISTRATOR:	LUIS GONZALEZ		FACILITY TYPE:	740
ADDRESS:	827 RIVER STREET		TELEPHONE:	(805) 524-5080
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY:	66	CENSUS: 30	DATE:	12/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Luis Gonzalez		TIME COMPLETED:	03:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 10:08 a.m. The LPA met with Administrator Luis Gonzalez and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers were last inspected on 1/06/2023. The carbon monoxide detectors were tested and functioned properly. The smoke alarms and fire suppression system were last tested 9/21/2023 by AA Technology & Electric; all functioned properly. There are three (3) stairwells and all of them lacked evacuation chairs.

KITCHEN: The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food as well as an emergency supply of food and water. BEDROOMS: The LPA observed ten randomly chosen rooms. Rooms were appropriately furnished, clean and had sufficient lighting. The hot water temperature was tested in three residents' rooms and was over the regulatory limit of 120*F. The temperatures were measured as follows: room 108 was 121.8*F, room 121 was 128.5*F, and room 204 was 127.4*F. RESTROOMS: Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. COMMON SPACES: The lobby, activity rooms, dining room, lounge areas, theater, gym, and hair salon were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio area was equipped with furniture for residents' use.

(continued on 809-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 12/06/2023 03:40 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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during facility inspection, the licensee did not comply with the section cited above in three (3) out of three (3) stairwells, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator will order three evacuation chairs for each of the three stairwells located in the facility and provide proof of the order and expected delivery date to CCL on or before 12/8/2023. Once the chairs have been received and placed in the stairwells, Administrator will provided photos of the placement of the chairs to CCL.

Type A

Section Cited

CCR

87303(e)(2)

87303 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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation through temperature testing, the licensee did not comply with the section cited above in three (3) out of three (3) resident room faucets tested (readings were 121.8F, 128.5F, 127.4*F), which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administrator immediately turned the water heater temperature down during the visit. He will check temperatures in the rooms to ensure the temperature is between 105F - 120F and send photos of the temperature readings to CCL on or before 12/08/2023.

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 Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
	VISIT DATE: 12/06/2023

NARRATIVE

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(continued from 809)

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

RESIDENTS AND STAFF: LPA reviewed five residents' files and five staff files; all were complete. Medications were reviewed and appear to be given as prescribed. LPA interviewed three residents and three staff; no concerns were noted.

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 was conducted with Administrator Luis Gonzalez. Report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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