565850261-8-22-2024-29-AS-MARO-D8DTWZ-20240822150618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850261
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:06:46 PM

Document Has Been Signed on 08/22/2024 03:06 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:	ABOVE AND BEYOND HOME CARE		FACILITY NUMBER:	565850261
ADMINISTRATOR:	SALUNGA, ALBERT		FACILITY TYPE:	740
ADDRESS:	6217 ANASTASIA ST		TELEPHONE:	(747) 210-1660
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Analyn Cervantes		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were four (4) staff and five (5) residents present. LPA met with the Administrator, Analyn Cervantes and explained the reason for the visit. Entrance interview conducted.

The LPA 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. The following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 9:51 a.m. Knives and sharps were observed in a locked drawer next to the gas range. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 106.7 degrees Fahrenheit at 9:54 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 9:59 a.m., hardwired combination smoke and carbon monoxide detectors were tested, and all were functional at the time of the visit. Two (2) fire extinguishers were observed and fully charged on 08/09/2024. No fire clearance concerns were observed. The LPA observed required postings throughout the common space. Activities were observed in the common areas. LPA observed working auditory alarms 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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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: ABOVE AND BEYOND HOME CARE	FACILITY NUMBER: 565850261
	VISIT DATE: 08/22/2024

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Report Continued from LIC 809...

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. Starting at 9:36 a.m., the water temperature was measured in both bathrooms, and they measured between 105- and 120-degrees Fahrenheit.

BEDROOMS: There are four (4) total bedrooms in the facility; two (2) are designated as shared rooms and two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. LPA observed a closet with additional clean linens, blankets, and towels for resident use. There is a locked closet with resident’s personal hygiene items inaccessible to residents in care. No staff room on premises.

GARAGE/BACKYARD: The garage was inaccessible to residents at the time of the visit. Washer and dryer were observed inside the garage. LPA observed a refrigerator with additional food for resident use. Laundry detergent was observed locked and inaccessible. LPA observed an adequate amount of emergency food and water. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear of obstructions. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 10:11 a.m. and Personnel Records at 11:05 a.m.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

Four (4) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were complete. The Administrator’s certificate is active and expires on 01/08/2025.

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: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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: ABOVE AND BEYOND HOME CARE	FACILITY NUMBER: 565850261
	VISIT DATE: 08/22/2024

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Report Continued from LIC 809C...

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 07/15/2024.

MEDICATIONS: Medications review began at approximately 12:55 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

During today’s visit, LPA conducted interviews with one (1) staff and one (1) resident. LPA also obtained copies of Personnel Report, Resident Roster, Emergency Disaster Plan, and Limited Liability Insurance.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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