567609955-10-26-2021-29-AS-JROS-C86UC3-20211026152716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609955
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:28:57 PM

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:	VARSITY MANOR, LLC, THE		FACILITY NUMBER:	567609955
ADMINISTRATOR:	TECSON, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	4656 VARSITY ST		TELEPHONE:	(805) 676-0337
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 2	DATE:	10/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Alexander Tecson		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required -1 Year inspection. LPA met with Administrator Alexander Tecson. Upon arrival LPA met staff #1 (S1) who is fingerprint cleared but not associated to the facility. LPA observed S1 cutting up food in the kitchen. S1 stated that they started working at the facility yesterday. Administrator stated that S1 just started working at the facility and they are in training. LPA observed 2 visitors in the facility upon LPA's arrival that were not screened. During facility tour to inspect for infection control practices LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted. LPA observed the fire extinguishers fully charged. The smoke alarms and carbon monoxide detector were tested and were operable. Outdoor area toured- passageways are free of obstruction. During facility tour at 11:20 am with S2 LPA observed metformin tablets and glipizide tablets belonging to S2 in an unlocked staff room accessible to residents. During facility tour at 12:05 am with Administrator LPA observed hot water temperature at 132.3 degrees F. in resident bathroom. During facility tour at 12:06 pm with Administrator LPA observed a room in the garage with a bed and night stand that is not on the facility sketch. Administrator stated that the the licensee is a contractor and he had the room built. Administrator stated that they do not have documentation of the building permits. During review of infection control practices with Administrator at 1:03 pm Administrator stated that they do not Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

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: VARSITY MANOR, LLC, THE	FACILITY NUMBER: 567609955
	VISIT DATE: 10/26/2021

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 26 27 28 29 30 31 32	have a health screening and TB test on file for S1. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalty assessed in the amount of $100.00. Exit interview conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: VARSITY MANOR, LLC, THE	FACILITY NUMBER: 567609955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature tested at 132.3 F. in resident bathroom which poses an immediate safety risk to persons in care.
	POC Due Date: 10/26/2021
	Plan of Correction
1 2 3 4	Administrator turned down water heater temperature during facility visit.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as S2's medications were accessible to residents in an unlocked staff room which poses an immediate health risk to persons in care.
	POC Due Date: 10/27/2021
	Plan of Correction
1 2 3 4	Staff removed medications from staff room. Administrator will provide a locked locker for S2 to place medications in. Administrator stated that the will provide documentation of scheduled staff training regarding storage space to CCL by 10/27/21.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 3 of 6

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: VARSITY MANOR, LLC, THE	FACILITY NUMBER: 567609955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

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: (2) 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 interview and record review, the licensee did not comply with the section cited above in 1 out of 2 staff which poses an immediate safety risk to persons in care.
	POC Due Date: 10/26/2021
	Plan of Correction
1 2 3 4	S1 requires to obtain criminal record ransfer. Administrator provided copies of criminal background clearance transfer request, LIC508 and photo identification during facility visit. Administrator stated that they will not have any staff working that is not fingerprint cleared and associated to the facility.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: VARSITY MANOR, LLC, THE	FACILITY NUMBER: 567609955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in 1 out of 2 staff which poses a potential health risk to persons in care.
	POC Due Date: 11/03/2021
	Plan of Correction
1 2 3 4	Administrator stated that they will provide documentation of S1's health screening and TB test to CCL by 11/3/21.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: VARSITY MANOR, LLC, THE	FACILITY NUMBER: 567609955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as a room was observed in the garage without documentation of a building permit which poses a potential safety risk to persons in care.
	POC Due Date: 11/05/2021
	Plan of Correction
1 2 3 4	Administrator stated that he will provide documentation of a building permit and an updated sketch for the bedroom in the garage to CCL by 11/5/21.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC809 (FAS) - (06/04)

Page: 6 of 6