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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850347
Report Date: 08/27/2024
Date Signed: 08/28/2024 08:39:08 AM

Document Has Been Signed on 08/28/2024 08:39 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:MOM'S PLACE 3FACILITY NUMBER:
565850347
ADMINISTRATOR/
DIRECTOR:		IBIRONKE, YUSUFFACILITY TYPE:
740
ADDRESS:975 VALLEY VISTA DRIVETELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 2DATE:
08/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Laila Landu Kulungu - facility representative. TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to this facility and met with, Laila Landu Kulungu - facility representative. The case management visit is being conducted due to deficiencies observed during the investigation of complaint control # 29-AS-20240823160942.

Based on observations, interviews and file review, LPA discovered the Licensee did not submit a written death report for Resident 1 (R1) and an incident report for Resident 2 (R2). At 10:45 A.M., LPA interviewed facility Staff #1 (S1) who stated that R1 passed away a couple of months ago. In May 2024, R2 was taken to the hospital for a thumb infection while in care. After reviewing resident's folders and the facility's e-file under Community Care Licensing (CCL) Regional Office (RO), LPA discovered that since licensure, facility has not submitted any incident reports nor death reports to CCL. LPA advised that within seven days (7) of a death, a written report shall be submitted to Community Care Licensing (CCL). Administrator did not notify CCL within the required time frames.

Interviews with facility representative and administrator reflected that facility administrator does not come to the facility often due to distance. Administrator stated that she visits the facility once in a while. Additionally, it was revealed that the facility representative acts as the facility administrator and is the administrator for all of the sister facilities located in Thousand Oaks and Camarillo.

Continues on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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: MOM'S PLACE 3
FACILITY NUMBER: 565850347
VISIT DATE: 08/27/2024
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Continued from LIC 809

Moreover, LPA reviewed two (2) files for Resident #3 (R3) and Resident #4 (R4). Both residents living at the facility at the time of the visit are diagnosed with dementia. Their Physician's reports were complete more than a year ago. LPA explained that licensees who accept and retain residents with dementia shall have this assessment done annually which shall include a reassessment of the resident’s dementia care needs.

Both administrator and the facility representative were not able to be present during the LPA's entire visit today. Administrator designated staff Howard Suanes to sign and receive report.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies and civil penalties were cited (refer to LIC 809-D).

Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/28/2024 08:39 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/27/2024 at 01:40 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: MOM'S PLACE 3
FACILITY NUMBER: 565850347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia. (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment... include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Licensee will submit physician's report for R3 and R4 before POC due date.
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Based on resident records review the licensee did not comply with the section cited above as R1 and R2's physician's reprot was not done annually which poses a potential health, safety and personal rights risk to residents in care.
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Type B
09/10/2024
Section Cited
CCR87405(a)

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87405 Administrator (a) All facilities shall have a qualified and currently certified administrator...The administrator... shall be on the premises a sufficient number of hours to permit adequate attention... specified in this section. This requirement is not met as evidenced by:
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Licensee will write a statement of understanding regarding regulation 87405(a). Licensee will make sure that administrator is at the facility at least 20 hrs. a week or find a replacement before POC due date.
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Based on interviews with staff, the licensee did not comply with the above cited section, as there was no qualified administrator running the facility for several days due to distance, which posed a potential health and safety risk to persons in care.
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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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2025 11:36 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/29/2024 12:32 PM


Created By: Valeria Conway On 08/27/2024 at 02:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOM'S PLACE 3
FACILITY NUMBER: 565850347

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2024
Section Cited
CCR
87211(a)(1)(A)

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87211(a)(1) Reporting Requirements - (1) A written report shall be submitted to the licensing agency and to the person responsible... if any; and disposition of the case.
This requirement was not met as evidenced by:
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Licensee will write a statement of understanding on regards Reporting requirements and submit R2's incident report to CCL before POC due date.
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Based on information gathered during the investigation the licensee did not comply with the section cited as CCL was not notified of an incident that happened to R2 while in care and a death report from 2 months ago. This poses as a potential health and safety risks to residents in care.
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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: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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