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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850271
Report Date: 08/19/2024
Date Signed: 08/20/2024 08:29:28 AM

Document Has Been Signed on 08/20/2024 08:29 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SOMIS LIVING IFACILITY NUMBER:
565850271
ADMINISTRATOR/
DIRECTOR:		CACAL, JOCELYNFACILITY TYPE:
740
ADDRESS:4111 SAND CANYON RDTELEPHONE:
(805) 386-4145
CITY:SOMISSTATE: CAZIP CODE:
93066
CAPACITY: 6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jocelyn CacalTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At 10:30 a.m. Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Jocelyn Cacal and informed the reason for the visit.

At 11:15 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. Somis #1 has a backhouse. Backhouse is licensed under Somis #2. LPA is only conducting an annual at Somis #1.

The following was observed:

Facility is a single-story residence that consists of five (5) resident rooms, one (1) staff room, three resident bathrooms and one staff bathroom. The LPA observed fire extinguishers throughout the facility, which were purchased on 08/12/2024 and fully charged. Carbon monoxide and smoke alarms are hardwired. At 12:07 P.M. 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 11:45 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. Facility has sufficient amount of emergency food and water at the time of the visit. Knives and sharps are stored in a locked drawer. All cleaning compounds were locked under the sink and in areas separately from food supplies. At 11:48 A.M. hot water measured 109.3 degrees Fahrenheit.

Continues on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SOMIS LIVING I
FACILITY NUMBER: 565850271
VISIT DATE: 08/19/2024
NARRATIVE
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Continued from LIC 809

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. The bedrooms were large enough to allow for easy passage between the beds and furniture. In addition, no bedrooms were used as a passageway to another room, bathroom, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. All toilets were in working conditions. LPA measured hot water in all bathrooms. Hot water in all bathrooms are within the allowable range of 105 degrees F to 120 degrees Fahrenheit.



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 and in room #1, which are covered with a screen. Facility maintained a comfortable temperature of 76 degrees. There were no obstructions and/or tripping hazards throughout the facility. Facility has a fire door to separate the left wing from the right wing of the house. Magnet or automatic closing mechanism that shall hold fire door open is broken. During today's visit LPA observed licensee using a door wedge to hold open fire door. LPA explained that fire doors must be kept closed and the usage of stoppers is prohibited.

Surrounding Grounds (Outdoors, Garage and Shed): Front yard and backyard had appropriate outdoor furniture, with a covered shaded area for residents. There is plenty of room for outdoor activities. There are no bodies of water on the premises. Garage was locked at the time of the visit. Laundry room is inside the locked garage. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. There is a shed behind the main house. Shed was locked and stores extra supplies for resident use.

Continues on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SOMIS LIVING I
FACILITY NUMBER: 565850271
VISIT DATE: 08/19/2024
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Continued from LIC 809-C

Record Review: At 1:30 P.M. a review of facility files was initiated. The LPA reviewed five (5) out of (5) resident files. All documents reviewed appeared complete except admission agreements. During the record review, LPA observed that the admission agreement currently in use do not include the complete or proper facility name. LPA explained to Administrator, this omission could lead to potential misunderstandings or legal complication between Somis 1 and Somis 2. Furthermore, LPA reviewed six (6) staff files. All documents reviewed appeared complete. During records review, LPA observed that staff #1 (S1) is not associated to the facility. Information gathered during the course of the visit and a review of the Guardian System reflected that S1 hired date was 07/22/2024. Administrator understands that S1 is unable to work at the facility until association is complete. Last emergency drill was conducted on 07/28/2024.

Medications: At 2:15 P.M., medications review was initiated. Medications are centrally stored and locked in a locked cabinet in the office 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.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/20/2024 08:29 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/19/2024 at 03:03 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: SOMIS LIVING I
FACILITY NUMBER: 565850271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above by keeping fire door open with a stopper which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee closed fire door and stated that fire door will remain closed at all times. Licensee will provide a statement of understanding on fire clearance.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onrecord review, the licensee did not comply with the section cited above in 1 out of 6 staff member was not associated to Somis I, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee will submit association form to Department to make sure that S1 is associated 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
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/20/2024 08:29 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/19/2024 at 03:03 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: SOMIS LIVING I
FACILITY NUMBER: 565850271

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 5 resident's admission agreements did not include the complete or proper facility name which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2024
Plan of Correction
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Licensee will have residents/resident's representative to sign and date new admission agreements including SOMIS 1 information on first page before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


LIC809 (FAS) - (06/04)
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