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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802411
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:17:14 PM


Document Has Been Signed on 06/02/2023 03:17 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:ANITA'S CARE VILLAFACILITY NUMBER:
565802411
ADMINISTRATOR:SHAFFER, JENNIFERFACILITY TYPE:
740
ADDRESS:521 LOUIS DRIVETELEPHONE:
(805) 716-3633
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY:6CENSUS: 5DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer ShafferTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. The LPA met with Administrator Jennifer Shaffer and explained the reason for the visit.

The LPA,and staff toured the physical plant areas at 9:45 a.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA began the inspection in bedroom area at 9:45 a.m. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. The LPA observed accessible over the counter medications and prescription medications in a box in bedroom #4.

RESTROOMS: The two client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 118.2 degrees Fahrenheit. Accessible prescription mouthwash was observed by the LPA at 9:51 a.m. and unlocked cabinet in the hallway bathroom, cleaning supplies and hygiene items were observed to be unlocked under the kitchen sink. Accessible cleaning supplies were observed in bathroom inside bedroom #4. All accessible items were locked at the time of the visit.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food and non-perishable food. At 10:05 a.m., the LPA and the Administrator observed expired grape juice dated 5/4/2023, exposed bag of powdered mash potatoes with unverifiable expiration date, exposed pancake mix with unverifiable expiration date, moldy broccoli in the refrigerator along with expired tomatoes, cabbage, exposed cut vegetables, open bag of frozen shrimp with freezer burn, open bag of frozen waffles with freezer burn, and exposed frozen meats with freezer burn. Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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 06/02/2023 03:17 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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning supplies were found accessible throughout the facility, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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The Licensee agreed to do the following:
1. Lock all cleaning supplies and accessible items and notify CCL no later than 6/3/2023. All items locked at time of the visit.
Type A
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 out of 5 residents did not have signed resident rights, signed consent forms and 1 out of 5 residents did not have a needs and services plan which poses an immediate personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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The Licensee agreed to the following:
1. To have required forms signed and completed no later than 6/3/2023 and provide proof to CCL.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2023 03:17 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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there were expired foods and foods exposed to freezer burn found in the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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The Licensee agreed to the do the following:
1. Discard of any expired foods and notify CCL. POC was cleared at the time of the visit.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the centrally stored medication cabinet was observed to be unlocked in the kitchen, prescription mouthwash was observed in hallway bathroom and prescription and over the counter medications were observed unloced in Residetn #4 room which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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The Licensee agreed to the do the following:
1. Lock accessible medicaitons. POC was cleared at the time of the visit.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2023 03:17 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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the single latch exit door on the side of the house was not even an not allowing for it to close or open properly. Storage shack door was in disrepair leaving accessible items exposed such as gardening supplies and chemicals which poses a potential health and safety risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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The Licensee agreed to the following:
1. Repair side door and stroage shack door and notify CCL no later than 6/9/2023.
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2023 03:17 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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsevation, the licensee did not comply with the section cited above as the first aid kit was not complete and missing twezzers, thermometer, first aid manual which poses a potential health and safety risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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The Licensee agreed to the following:
1. Replace missing items or obtain a complete first aid kit and notify CCL no later than 6/9/2023.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
VISIT DATE: 06/02/2023
NARRATIVE
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The Administrator was advised to do a deep cleaning of the kitchen and conduct an audit of their food items. Staff cleaned refrigerator and disposed of expired items at the time of the visit. Centrally stored medication is kept in a kitchen cabinet which was observed to be unlocked at the time of the visit.

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. Fire extinguisher was observed to be serviced on 4/10/2023 and fire alarm was tested at 10:28 a.m. and observed to be functioning at the time of the visit.

The facility maintained a temperature of 73 degrees. All exits have functioning auditory devices. The LPA and the administrator observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching however was observed to be in disrepair. Storage shack was observed to be unlocked as the door was in disrepair, storage shack contained gardening supplies and chemicals accessible to residents in care. There were no bodies of water noted. The garage is attached to the home which houses the laundry area. The garage was locked at the time of the visit.

RECORDS: Residents’ records review began at 10:50 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. 2 out of 5 records were in order. Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) were missing singed resident rights and signed consent forms additionally R1 was missing a needs and services plan. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:45 p.m., medications are centrally stored and kept in a locked cabinet in the kitchen which was observed to be unlocked at the time of the visit. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
VISIT DATE: 06/02/2023
NARRATIVE
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The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster.

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. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 7 of 7