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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802426
Report Date: 07/06/2021
Date Signed: 07/06/2021 03:46:24 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 TULL STFACILITY NUMBER:
565802426
ADMINISTRATOR:PRAVEEN SYAMALAFACILITY TYPE:
740
ADDRESS:5603 TULL STTELEPHONE:
(805) 494-4121
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 5DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Praveen SyamalaTIME COMPLETED:
03:18 PM
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Today's evaluation included but was not limited to building and grounds, resident rooms, bathrooms, hot water temperature (read at 109.8 degrees F.) in resident bathroom, common areas, personal accommodations, food and first aid supplies. Licensing Program Analysts (LPA)'s JoAnn Rosales and Martha Guzman-Chavez observed lamps/lights for each room. LPA's observed fire extinguishers fully charged. Centrally stored medicines are kept in a locked kitchen cabinet and locked box in the refrigerator. Hygiene items are being provided. Grab bars and non-skid materials were present in the bathrooms. LPA's observed facility temperature at 76 degrees. Smoke alarms and carbon monoxide detectors were tested and operable. Indoor and outdoor area toured passageways were free from obstruction. LPA's reviewed resident records and medications. LPA Rosales reviewed staff records. Disaster drills are being conducted at least quarterly for each shift. The last disaster drill was conducted on 6/30/21.

During facility tour on 7/6/21 at 10:11 am with staff Emma Cacho LPA's observed dish soap in kitchen on sink accessible to residents.

During facility tour on 7/6/21 at 10:33 am with staff Emma Cacho LPA's observed lotion, efferdent denture cleanser and toothpaste in resident bathroom accessible to residents.

LPA Rosales spoke with Administrator on 7/6/21 starting at 10:42 am 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

Continued on 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
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: NAVITA RESIDENCE TULL ST
FACILITY NUMBER: 565802426
VISIT DATE: 07/06/2021
NARRATIVE
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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 and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 TULL ST
FACILITY NUMBER: 565802426
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2021
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’s 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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Type A
07/06/2021
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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2021
LIC809 (FAS) - (06/04)
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