<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802464
Report Date: 02/28/2022
Date Signed: 03/01/2022 07:49:52 AM


Document Has Been Signed on 03/01/2022 07:49 AM - 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:EMBRACING SENIORSFACILITY NUMBER:
565802464
ADMINISTRATOR:TRUPIANO, JOSEPHFACILITY TYPE:
740
ADDRESS:729 MUIRFIELD AVETELEPHONE:
(805) 422-8441
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Joseph TrupianoTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 01:17 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Joseph Trupiano at 1:43 p.m. 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 carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was last serviced 09/21/2021.

KITCHEN: Knives were found in an unlocked drawer and cleaning supplies were found in an unlocked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All medications were stored in locked cabinets. BEDROOMS: The LPA observed two single-occupancy resident bedrooms and two shared bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean and sanitary and in operating condition. LPA observed room deodorizer in an unlocked drawer. COMMON SPACES: The living room, family room and dining room furniture were observed to be in good condition. The front yard is gated, has a patio area, and is equipped with furniture for resident use. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Infection control postings were observed. The facility had 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.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).


Exit interview conducted. Today's reports and appeal rights were discussed and issued. Report was signed by staff Amparo Yuzon as the administrator needed to leave at 2:45 p.m. for an appointment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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 2


Document Has Been Signed on 03/01/2022 07:49 AM - 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: EMBRACING SENIORS
FACILITY NUMBER: 565802464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed knives and scissors stored in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
1
2
3
4
Staff secured the knives and scissors in a locked drawer. Administrator will provide evidence of training staff on securing dangerous items to CCL on or before 03/04/22.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed cleaning supplies stored in an unlocked cabinet in the kitchen, an unlocked drawer in the bathroom and an unlocked closet in the hallway, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
1
2
3
4
Staff secured cleaning supplies in a locked cabinet in the kitchen and in the locked garage. Administrator will provide evidence of staff training regarding securing toxic substances to CCL on or before 03/04/22.

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: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2