565850244-6-16-2023-29-AS-ECOZ-CSUVUG-20230616164443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850244
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:46:02 PM

Document Has Been Signed on 06/16/2023 04:46 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PALS SKILLS CENTER		FACILITY NUMBER:	565850244
ADMINISTRATOR:	POURAN MOUSAZADEH		FACILITY TYPE:	775
ADDRESS:	1310 E MAIN STREET		TELEPHONE:	(562) 489-3859
CITY:	SANTA PAULA	STATE: CA	ZIP CODE:	93060
CAPACITY: 30		CENSUS: 2	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Pouran Mousazadeh		TIME COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Esther Cortez and Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 9:00 a.m. The LPAs met with Administrator Pouran Mousazadeh and explained the reason for the visit. Upon arrival, there were no consumers in the building, as the two (2) enrolled consumers were on an outing with staff. The program currently operates from 8:00 a.m. to 2:00 p.m. The day program was staffed with 1:1 staff to consumer ratios. Temperatures of staff, consumers and visitors are taken upon entry into the facility.

Common Activity Space: The facility is a single-story structure with a large conference room, two (2) small meeting rooms, one (1) relaxing room, one (1) art room, two (2) computer areas, two (2) bathrooms, and two (2) kitchens. The LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. The LPA observed fire extinguishers throughout the facility, which were last serviced 03/17/2022. Administrator stated the fire marshals would service the fire extinguishers on 6/19/2023.

Activities: Activities are both designed for individual and as a group. The two (2) enrolled consumers were at all day outings at the start of the visit; however, they returned prior to the end of the program.

Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. At 09:42 a.m., water temperature in the restroom was measured at 117.5 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Report will continue on LIC809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SKILLS CENTER	FACILITY NUMBER: 565850244
	VISIT DATE: 06/16/2023

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Record Review: At 10:00 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and Insurance liability. The LPA obtained Client Roster, Staff Roster, and facility Sketch. The LPA reviewed two (2) of (2) Client Files. One (1) of two (2) client files (C1) did not have LIC613 Personal Rights forms. The LPA reviewed three (3) of three (3) staff files. One (1) of three (3) staff (S1) files did not have LIC503 Health screening form. Administrator stated they would request LIC503 from S'1 physician and provide to licensing once they receive it.

Medications: At this time, the facility does not centrally store medications for consumer use.

Infection Control: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility keeps record of staff and consumer vaccinations. The facility's procedures as it pertains to infection control are adequate.

Interview: During today's visit, the LPA interviewed two (2) staff and one (1) consumer. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2023 04:46 PM - It Cannot Be Edited

Created By: Esther Cortez On 06/16/2023 at 03:57 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SKILLS CENTER	FACILITY NUMBER: 565850244
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82020

Fire Clearance

All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. 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 as all fire extinguishers throughout the facility were last serviced 03/17/2022 past the annual requirement which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	Administrator stated the fire marshals would service the fire extinguishers on 6/19/2023. Administrator will sent proof to CCL by end of day on POC due date.

Type B

Section Cited

CCR

82065(g)(1)

Personnel Requirements

(1) The good physical health of each employee and individual licensee shall be verified by a health screening, including negative test results for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one (1) of three (3) staff (S1) files did not have LIC503 Health screening forms, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/26/2023
	Plan of Correction
1 2 3 4	Administrator stated they would request LIC503 from S'1 physician and provide to licensing once they receive it. Administrator will send a copy of S'1 health screening no later than end of day on 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

LICENSING EVALUATOR NAME:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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