567610000-1-8-2024-29-AS-ECAS-CZAU5B-20240108141627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610000
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:16:41 PM

Document Has Been Signed on 01/08/2024 02:16 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:	ERTEN HOME CARE		FACILITY NUMBER:	567610000
ADMINISTRATOR:	ROSALES, KAREN		FACILITY TYPE:	740
ADDRESS:	212 ERTEN ST.		TELEPHONE:	(818) 219-5998
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 2	DATE:	01/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Karina Antig		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. The LPA was greeted by staff, Administrator Karina Antig arrived shortly thereafter and informed them of the reason for the visit.

The LPA and 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is blocked by a tv console and inaccessible. The facility maintained a comfortable temperature of 75 degrees. Smoke detector(s) and carbon monoxide detector were tested at 11:40 a.m. and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last purchased May 18, 2023. The LPA observed required postings throughout the common space. The laundry is located in the hallway behind the kitchen. All laundry supplies are locked and inaccessible.

KITCHEN: Kitchen/food service area was inspected at 10:25 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: There are five designated resident rooms and one staff room. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Linens are kept in a hallway closet.

BATHROOMS: The resident 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 in bathrooms measured between 127.0-131.0 degrees Fahrenheit.

Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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: ERTEN HOME CARE	FACILITY NUMBER: 567610000
	VISIT DATE: 01/08/2024

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OUTDOOR AREA: The backyard has an outdoor area equipped with furniture and shade for client use. There is a side gate for resident exit and is single latched. No bodies of water noted. The garage contains an additional refrigerator with perishable food items. Additional nonperishable food was observed along with emergency food and water. Cleaning supplies and disinfectants are kept in locked in the garage.

RECORDS: Residents’ records review began at 12:55 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:05 p.m.; medications are centrally stored and locked in a cabinet in the kitchen above the microwave. 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.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- 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 issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2024 02:16 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: ERTEN HOME CARE	FACILITY NUMBER: 567610000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as in faucets in resident bathrooms were delivering water above 120 degrees fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/09/2024
	Plan of Correction
1 2 3 4	The Administrator agreed to the following: 1. Adjust water temperature so that water is delivered between 105-120 degrees F. POC met at the time of the visit. 2. Track water temps for the following 5 days to ensure water temps are staying within limits and provide proof to CCL no later than 1/16/2023.

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: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC809 (FAS) - (06/04)

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