565850167-11-3-2023-29-AS-MARO-CX8S5Q-20231103133443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850167
Report Date: 11/03/2023
Date Signed: 11/03/2023 01:34:58 PM

Document Has Been Signed on 11/03/2023 01:34 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:	CASA BLANCA SENIOR LIVING		FACILITY NUMBER:	565850167
ADMINISTRATOR:	VIGIL, MONICA		FACILITY TYPE:	740
ADDRESS:	5631 EUNICE AVE.		TELEPHONE:	(805) 218-0397
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	4	CENSUS: 4	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Monica Vigil		TIME COMPLETED:	01:45 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual inspection at 8:15 a.m. The last annual conducted at this facility was on 11/22/2022. When the LPA arrived, there were two staff and four residents present. Upon arrival, the LPA was scanned and greeted at the door by staff Kat Walker and Administrator Monica Vigil, at this time the reason for the visit was explained. Entrance interview conducted.

The LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 8:20 a.m. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. Knives and sharps stored inside a box in a locked cabinet in the kitchen. Cleaning supplies and disinfectants are stored under the kitchen sink inaccessible to residents. At 8:31 a.m., the hot water temperature was measured in the kitchen at 113.5 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is adequately screened and inaccessible. The facility maintained a comfortable temperature. At 9:00 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and last serviced on 11/15/2022. The LPA observed required postings throughout the common space.

GARAGE: The garage is kept locked and inaccessible at all times. The washer and dryer were observed inside the garage. The LPA observed a sufficient supply of emergency water. At 8:50 a.m., the LPA observed a few food items that were expired; these included canned fruit (09/2023) and canned soup (08/2023). Items were immediately discarded. Cleaning supplies, detergents, and disinfectants were observed locked and inaccessible at the time of the visit.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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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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: CASA BLANCA SENIOR LIVING	FACILITY NUMBER: 565850167
	VISIT DATE: 11/03/2023

NARRATIVE

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(Report Continued from LIC 809...)

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. At 8:35 a.m., the LPA observed two self-latching gates; however, both passageways had items obstructing the passageways. The Administrator had passageways cleared at the time of the visit. There were no bodies of water noted at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) designated private bedrooms and one (1) staff room. Each bedroom has its own supply of clean towels and linens; however, there is a linen cabinet in the hallway with extra towels, blankets, and linens.

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; the first bathroom measured 112.1 degrees Fahrenheit at 8:43 a.m.; and the second bathroom measured 106.8 degrees Fahrenheit at 8:48 a.m.

RECORDS: Records review began at 9:07 a.m.; four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Although the facility has a designated training binder, the LPA was unable to determine the number of hours completed per regulation for the past 12 months. The facility has not conducted an emergency drill in the last 12 months. Administrator stated the facility will schedule one soon.

MEDICATIONS: Medications review began at approximately 12:15 p.m. The medications are centrally stored and locked in a cabinet by the kitchen. PRNs were labeled, stored, and inaccessible to residents. PRNs have physicians order on file. 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.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: CASA BLANCA SENIOR LIVING	FACILITY NUMBER: 565850167
	VISIT DATE: 11/03/2023

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(Report Continued from LIC 809C...)

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. 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 a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate.

At approximately 1:00 p.m., the LPA interviewed one (1) staff member and two (2) residents.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Client Roster, Emergency Disaster Plan, and limited liability insurance.

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 conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/03/2023 01:34 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: CASA BLANCA SENIOR LIVING	FACILITY NUMBER: 565850167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as miscellaneous items were obstructing the outdoor passageways, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	The Administrator cleaned up the items and cleared the outdoor passageways at the time of the visit. POC has been met.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interviews conducted, the licensee did not comply with the section cited above as the facility has not had an emergency evacuation drill in the last 12 months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	The Administrator has agreed to conduct emergency disaster drill and submit proof to CCL by POC due date.

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) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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