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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221159
Report Date: 07/31/2023
Date Signed: 07/31/2023 04:49:37 PM

Document Has Been Signed on 07/31/2023 04:49 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAHARLIKA HOMESFACILITY NUMBER:
191221159
ADMINISTRATOR:GARDOSE, NOELLIE L.FACILITY TYPE:
740
ADDRESS:17843 CANTARA STREETTELEPHONE:
(818) 343-3936
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 4DATE:
07/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Monique Gardose-Assistant AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 07/31/23 Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced Case Management-Incident visit to this facility. The purpose of the case management visit was to follow up on a special incident report dated 07/12/23 and incident occurred 07/11/23.

It was reported that Resident#1(R1) fall due to the absence of supervision and had been hospitalized and treated with sutures. LPA interviewed Direct Care Staff (S1) and Assistant Administrator (S2) regarding the incident. During the course of investigation, LPA obtain digital copies of Individual Program Plans (IPP), Physician's Report, Discharge Documents, Doctor's Follow up Notes, Resident in Home Schedule and 24 hour Staff Schedule.

Based on the information obtained during the investigation there is evidence that facility staff assigned to provide one-to-one supervision of R1, failed to provide adequate care and supervision by leaving R-1 unattended on 7/11/23. Deficiencies were issued on a Facility Evaluation Report / Lic. 809D. The Facility Assistant Administrator was advised, appeal rights given, and a copy of this report was issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2023
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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Document Has Been Signed on 07/31/2023 04:49 PM - It Cannot Be Edited


Created By: Mariana Agban On 07/31/2023 at 03:46 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAHARLIKA HOMES
FACILITY NUMBER: 191221159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2023
Section Cited
CCR
87411(a)

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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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The administrator has submit a digital copy of facility in service training occured on 7/13/23 implementing new policy regarding this resident.

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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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023


LIC809 (FAS) - (06/04)
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