565850271-8-11-2023-29-AS-ECOZ-CULUTB-20230811155140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850271
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:52:27 PM

Document Has Been Signed on 08/11/2023 03:52 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:	SOMIS LIVING I		FACILITY NUMBER:	565850271
ADMINISTRATOR:	CACAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4111 SAND CANYON RD		TELEPHONE:	(805) 386-4145
CITY:	SOMIS	STATE: CA	ZIP CODE:	93066
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jocelyn Cacal		TIME COMPLETED:	04:00 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	At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Jocelyn Cacal and informed them of the reason for the visit. At 09:23 a.m. the LPA conducted a tour of the physical plant with Administrator Jocelyn to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident rooms, one (1) staff room, two resident bathrooms and two staff bathrooms. The LPA observed fire extinguishers throughout the facility, which were purchased on 7/17/2023 and fully charged. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour at 9:25 a.m. the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. Sharps and cleaning supplies are stored in locked drawer and cabinet. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 9:37 a.m. the LPA observed prescribed medication Polyethylene Glycol inside the unlocked staff room, accessible to residents in care. Upon observation the administrator locked the staff room. At 9:45 a.m. the LPA observed over the counter nasal spray, eye drops, bar of soap, and CryoDerm pain reliever roll in a small bag inside the nightstand of one of the residents (R1) in room 5, accessible to the residents in care. Upon observation, the administrator stored all items from room 5 inaccessible to the residents. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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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Document Has Been Signed on 08/11/2023 03:52 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOMIS LIVING I	FACILITY NUMBER: 565850271
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

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 as the LPA observed prescibed medication accesible to residents inside an unlocked staff room, and observerd over the counter nasal spray, eye drops, a bar of soap, and CryoDerm pain reliever roll in room 5 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Upon observation the Administrator removed all items from room 5 and locked staff room. The administrator stated that all items in room 5 were left by R1's wife during a visit and was unaware of the items.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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

FACILITY NAME: SOMIS LIVING I	FACILITY NUMBER: 565850271
	VISIT DATE: 08/11/2023

NARRATIVE

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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 02:44 p.m., water temperature in one of the restrooms was measured at 119.0 degrees Fahrenheit. During the visit the LPA observed both resident restrooms inside the residents rooms, room 5 being used as a passageway for residents in rooms 2,3 and 4.
Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. facility maintained a comfortable temperature of 76 degrees. There were no obstructions and/or tripping hazards throughout the facility.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for visitors. There are no bodies of water on the premises.
Infection Control: The community has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The community's cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if there is a confirmed case of COVID-19. The community's policies and procedures pertaining to infection control were adequate.
Record Review: At 11:06 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention and obtained Client and Staff rosters. The LPA reviewed five (5) out of (5) resident Files and five (5) out of twelve (12) staff files. All documents reviewed appeared complete and current.
Medications: At 1:07 p.m. a medications review was initiated. Medications are centrally stored and locked in a locked cabinet in the living area; 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.
Interviews: The LPA conducted two (2) client Interviews and two (2) staff interviews. No immediate concerns were voiced during the visit.

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 Jocelyn Cacal.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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