565850272-10-16-2023-29-AS-ECOZ-CWNTKY-20231016144843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850272
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:49:17 PM

Document Has Been Signed on 10/16/2023 02:49 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SOMIS LIVING II		FACILITY NUMBER:	565850272
ADMINISTRATOR:	CACAL, JOCELYN		FACILITY TYPE:	740
ADDRESS:	4115 SAND CANYON ROAD		TELEPHONE:	(805) 386-4145
CITY:	SOMIS	STATE: CA	ZIP CODE:	93066
CAPACITY:	4	CENSUS: 2	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jocelyn Cacal		TIME COMPLETED:	02:55 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 9:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year visit to the facility. Upon arrival the LPA met with Licensee Jocelyn Cacal. Entrance interview conducted and the reason for the visit was explained. A tour of the physical plant was conducted with the Licensee between 9:18am - 9:30am to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single story residence that consists of two (2) resident bedrooms and one (1) bathroom. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit. LPA observed all required postings in the living 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: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer in the kitchen. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed the bathroom clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in the bathroom. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in the bathroom during the physical plant tour. Hot water measured 117.4 Fahrenheit, within the required limit of 105-120 degrees. 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. Report will continue on LIC809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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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Document Has Been Signed on 10/16/2023 02:49 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOMIS LIVING II	FACILITY NUMBER: 565850272
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 5 staff (S1, S2) that were not associted to the facilitY, S1 was observed by the LPA to be working at the facility prior to association which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	POC has been met, Licensee submitted S1 and S2's association to the regional office during the time of visit and S1 and S2 will not work at the facility until associated. Civil Penalties assessed in the amount of $500.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOMIS LIVING II	FACILITY NUMBER: 565850272
	VISIT DATE: 10/16/2023

NARRATIVE

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Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

Record Review: At 09:50 a.m. a review of facility files was initiated. The LPA reviewed two (2) of two (2) Client Files. All documents reviewed appeared complete and current. The LPA reviewed five (5) of eight (8) staff files and the following was noted: two (2) staff (S1, S2,) were not associated to the facility. S1 was observed to be working at the facility by the LPA during the visit. Upon observation, the Licensee stated S1 has been working at the facility for 6 days, and S2 start day was going to be 10/21/23. Licensee submitted a transfer request to the regional office for S1 and S2 during the visit. The LPA advised the Licensee, S1 and S2 could not work at the facility until association was completed. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/03/2023). The LPA obtained Client Roster, Staff Roster, and facility Sketch.

Medications: At 1:45 p.m. a medications review was initiated for all residents. Medications are centrally stored and locked in a cabinet in the living room; 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: At 2:10 p.m. the LPA conducted two (2) staff Interviews. The LPA was not able to interview both residents due to residents being asleep.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Civil Penalties assessed in the amount of $500, $100 X 5 day. Failure to correct the deficiencies may result in additional civil penalties.

Exit Interview Conducted / Appeal Rights given / A Copy of the Report Issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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