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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801948
Report Date: 07/07/2021
Date Signed: 07/07/2021 11:31:46 PM

COMPREHENSIVE INSPECTION
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:NAVITA RESIDENCE EDGEMONT DRIVEFACILITY NUMBER:
565801948
ADMINISTRATOR:PRAVEEN SYAMALAFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRIVETELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Praveen SyamalaTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced annual inspection at the facility today. The LPA arrived at 1:50 PM and initially met with staff Max Julian and Endah Purwaningsih. Administrator of record Praveen Syamala arrived at 2:20 PM. The LPA informed the Administrator of the reason for today's inspection. Entrance interview conducted.

Today's evaluation included but was not limited to: building and grounds, resident rooms, bathrooms, hot water temperature (read at 115.4 degrees F and 114.6 degrees F) in common resident bathrooms, common areas, personal accommodations, food and first aid supplies. LPA observed lamps/lights as well as sufficient furnishings and linens for each room. LPA observed fire extinguisher fully charged and recently purchased. Centrally stored medicines are kept in a cabinet just outside the kitchen. Hygiene items are being provided. Grab bars and non-skid materials were present in the bathrooms. LPA observed facility to be a comfortable temperature throughout the visit. Smoke alarms and carbon monoxide detectors were tested at 5:30 PM and were operable at the time of the visit. According to Administrator, disaster drills are conducted quarterly; the facility’s last documented disaster drill took place on 6/30/2021. Indoor and outdoor area was toured at 1:57 PM passageways were free from obstruction. LPA reviewed resident records at 2:41 PM, staff records at 4:25 PM and medications at 3:35 PM.

Upon arrival at the facility at 1:50 PM and during the visit, until LPA informed Administrator, LPA observed the medicine cabinet, containing all residents’ medications to be unlocked and accessible to residents in care.

During facility tour at 2:11 PM with facility staff Max Julian and Administrator, LPA observed an unlocked cabinet in a restroom accessible to residents, which contained shaving cream, lotion, mouthwash, , Efferdent, and Polident denture cleaners, as well as a basket on the ground containing Febreze air freshener, shampoo, body wash, and toothpaste.
Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
VISIT DATE: 07/07/2021
NARRATIVE
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During facility tour at 2:17 PM with facility staff Max Julian and Administrator, LPA observed an unlocked kitchen drawer containing scissors and a knife. Additionally, at 2:20 PM in another unlocked kitchen drawer, LPA observed disposable razors, razor blades, a lighter, Expo dry erase board cleaner, and nail clippers accessible to residents in care.

During a review of resident records at 2:41 PM with Administrator, LPA observed at 3:10 PM, that Resident #1 (R1) and Resident #2 (R2) have physician’s reports on file indicating both residents have a need for total care. Administrator indicated that R1 no longer requires total care, but does not have a current physician’s report indicating the change in condition. Additionally, Administrator indicated R2 does not require total care, however, the physician's report indicates otherwise.

During today’s visit at 5:00 PM, LPA Dulek spoke with Administrator regarding the suspended Kidilams Corporation. Administrator stated that they have contacted the Franchise Tax Board Representative and they have indicated that the Corporation can continue to do business. Administrator stated that they have submitted the requested documents to the Franchise Tax Board to reflect no pending tax payments and it will take approximately 6 weeks to process. Administrator stated that the Corporation has been suspended since October 2020. Administrator stated that they did not have knowledge of the suspension until LPA Rosales notified them of the suspension on 6/30/2021.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted; today's reports and appeal rights were reviewed at 5:20 PM and issued via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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87705 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:
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Based on Based on LPA observations and record review, the licensee failed to ensure that knives, a lighter, razors, and scissors were stored inaccessible to residents with dementia which posed an immediate health risk to persons in care.
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Type A
07/08/2021
Section Cited

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87705 Care of Persons with Dementia. (f)(2)The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on LPA observations and record review, the licensee failed to ensure that toxic substances were stored inaccessible to residents with dementia which posed an immediate health risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: NAVITA RESIDENCE EDGEMONT DRIVE
FACILITY NUMBER: 565801948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

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87465 Incidental Medical and Dental Care (h) (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Based on observation, LPA observed the centrally stored medication cabinet unlocked and accessible to residents during the visit, which poses an immediate safety risk to residents in care.
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Type A
07/08/2021
Section Cited

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87205 Accountability of Licensee Governing Body (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.


This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above as the facilities corporation has been suspended with the CA Secretary of State since October 2020 which poses a potential personal rights risk to persons in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4