567610003-10-23-2024-29-AS-VCOY-DABRF2-20241023125825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610003
Report Date: 10/22/2024
Date Signed: 10/23/2024 12:58:31 PM

Document Has Been Signed on 10/23/2024 12:58 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:	CALIFORNIA NEEDS AND SERVICES		FACILITY NUMBER:	567610003
ADMINISTRATOR/ DIRECTOR:	KENNETH CARPENTER		FACILITY TYPE:	735
ADDRESS:	2630 COCHRAN STREET		TELEPHONE:	(805) 209-5819
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	10/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Arthur J. Harris		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Valeria Conway arrived at the facility unannounced to conduct a required Annual visit at 09:15 a.m. At the time of arrival, no one was in the home. The LPA contacted Administrator, Kenneth Carpenter via phone. Administrator was unavailable during today’s visit, but authorized Direct Care Staff, Arthur Harris to be present and sign today’s report. At 9:51 a.m. the LPA met with Direct Care Staff, Arthur Harris and explained the reason for the visit. At 10:05 a.m., the LPA toured the physical plant areas inside and outside, with Direct Care Staff to ensure there are no health and safety hazard and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) client bedrooms and two (2) bathrooms. This facility doesn’t have a staff room, facility provides 24/7 care. The facility is vendored through Tri-Counties Regional Center as a level 4i home. The Facility does handle cash resources for all clients. Surety Bond is current. BEDROOMS: LPA observed four single-occupancy resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are two resident restrooms which were observed clean, sanitary, and in operating condition with grab bars and non-skid surfaces at the time of visit. The LPA observed sufficient amounts of soap, and paper products. Hand-washing signs were observed at the time of the visit. Restroom one (1) hot water measured 107.6 Fahrenheit at 10:14 a.m. Restroom two (2) hot water measured 112.5 Fahrenheit at 10:17 a.m. Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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: CALIFORNIA NEEDS AND SERVICES	FACILITY NUMBER: 567610003
	VISIT DATE: 10/22/2024

NARRATIVE

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Continued from LIC 809

COMMON SPACES: Common area walls and flooring were observed for cleanliness and good condition. At the time of the visit, living room and dining room furniture observed to be in good condition. LPA observed cabinets next to the dining room table. In a locked cabinet LPA observed medication, a complete first aid kit with its manual and sharps. In an unlocked cabinet LPA observed emergency food and emergency water. LPA observed some non-perishable food items had expired or displayed outdated expiration dates. LPA requested Direct Care Staff that a staff member be assigned to check expiration dates on each can. LPA observed cameras throughout the common areas only and at the front door. Facility provides sufficient space to accommodate both indoor and outdoor activities. Smoke and carbon monoxide detector tested/operable during visit. Fire extinguisher was observed to be fully charged and last inspected 10/15/2024.

BACKYARD: No bodies of water noted. Trailer observed on the side of the house; used by off duty staff only. The front yard is free of obstructions The backyard has an outdoor area equipped with furniture and shade for client use.

GARAGE/LAUNDRY ROOM: The garage contains an additional fridge, a freezer, a washer and dryer. Clients have access to the garage and are able to do their laundry with staff assistance. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies. LPA observed an adequate supply of Personal Protection Equipment (PPE).

KITCHEN: Kitchen appliances were in operable condition. All cleaning supplies were observed to be properly stored under the kitchen sink and locked at time of visit. At 10:07 a.m., hot water temperature measured at 109.2 degrees Fahrenheit.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

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: CALIFORNIA NEEDS AND SERVICES	FACILITY NUMBER: 567610003
	VISIT DATE: 10/22/2024

NARRATIVE

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Continued from LIC 809-C

FILE REVIEW: A review of facility files was initiate at 10:52 a.m. and the following was observed. LPA reviewed seven (7) staff files including the administrator’s. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Additionally, LPA reviewed four (4) client’s files. Client’s records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. LPA emailed Administrator and Direct Care Staff, Functional Capability Assessment form and ID form to be included on client’s files. All other documents reviewed appeared complete and current.

MEDICATIONS: Medications are centrally stored and locked in a cabinet in the living room. Medications are labeled and checked for expiration dates. At 12:20 p.m., LPA reviewed medication for all 4 clients. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

During today’s visit the LPA obtained the LIC500 Personnel Report, LIC9020 Client Roster, Surety Bond and Liability Insurance. Last emergency drill was conducted on 10/01/2024.

No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024

LIC809 (FAS) - (06/04)

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