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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850273
Report Date: 10/27/2023
Date Signed: 10/27/2023 12:37:44 PM


Document Has Been Signed on 10/27/2023 12:37 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:NAVITA RESIDENCES YOUNGFACILITY NUMBER:
565850273
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:2024 YOUNG AVETELEPHONE:
(805) 917-2025
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Shila PandeyTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 9:25 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Shila Pendey arrived shortly thereafter.

The LPA and the Administrator 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.

KITCHEN: The LPA toured the kitchen/food service area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. At 9:45 a.m. the LPA observed unlocked refrigerated medications in the kitchen refrigerator. At 9:49 a.m. the LPA observed 3 boxes of expired saltine crackers dated 4/28/23, 3/21/23 and 8/28/23 and 3 expired packs of bread dated 9/17/23, 9/14/23 and 10/12/23. The administrator disposed of all identified expired foods. The facility has a sufficient supply of perishable and non-perishable food. At 10:45 a.m. the LPA observed that the facility did not have sufficient emergency food and water supply. Medications are located in a locked cabinet in the dining room area along with resident and staff files.

BEDROOMS/BATHROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Lighting was sufficient however LPA advised Administrator to replace a light bulb in resident bathroom #1 and resident Room #2. There are six designated resident rooms and one staff room. The three client bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured at 119.8 degrees Fahrenheit in the hallway bathroom.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. At 9:30 a.m. LPA observed that the couch in the living room is being used as a sleeping quarter for staff. Interview with staff confirmed that there are three live-in staff and two stay in the designated staff room and one sleeps in the living room.

Continued on LIC9099-C

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NAVITA RESIDENCES YOUNG
FACILITY NUMBER: 565850273
VISIT DATE: 10/27/2023
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There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees F. Smoke detector(s) and carbon monoxide detector were tested at 10:30 a.m. and operational at the time of the visit. The single fire extinguisher was fully charged and last purchased on 3/21/23. The LPA observed required postings throughout the common space. There is a laundry room located next to the staff room all cleaning and laundry supplies are kept locked and inaccessible.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted and exits are free of obstructions. There is a detached garage with an additional refrigerator with perishable and non-perishable food items. Cleaning supplies and disinfectants are kept locked in the garage.

Due to time constraints, the LPA will return at a later date to complete the inspection.

The LPA obtained the following documents:


- LIC9020 Client Roster
- Liability Insurance

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/27/2023 12:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: NAVITA RESIDENCES YOUNG
FACILITY NUMBER: 565850273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as refrigerated medications were observed to left unlocked and accessible in the kitchen refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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Licensee agreed to do the following:
1. Immediatley lock the medications and ensure they remain secured. Provide proof to CCL no later than POC date.
Type A
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as they did not have emergecny food supplies or water and relied on currect daily inventory which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/28/2023
Plan of Correction
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Licensee agreed to do the following:
1. Ensure that the facility has an adequate amount of emergency food and water. Provide oroof to CCL no later than 10/28/23.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/27/2023 12:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: NAVITA RESIDENCES YOUNG
FACILITY NUMBER: 565850273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as it was identified that one live-in staff currently sleeps on the couch in the living room which poses potential health personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee agreed to the following:
1. Provide appropriate living and sleeping quarters for live-in staff. Provide proof to CCL no later than 11/3/23.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as expired bread an crackers were identified which poses a potential health and safety risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee agreed to the following:
1. Dispose of expired food items. Plan of correction met at the time of the visit.
2. Conduct an audit of all food items. Provide proof to CCL no later than 11/3/23.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4