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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601489
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:55:53 PM

Document Has Been Signed on 09/16/2021 12:55 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARRIE'S BOARD AND CAREFACILITY NUMBER:
197601489
ADMINISTRATOR:CARRIE ACOSTAFACILITY TYPE:
740
ADDRESS:8430 COLBATH AVENUETELEPHONE:
(818) 893-7619
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 4DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CARRIE ACOSTATIME COMPLETED:
01:00 PM
NARRATIVE
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At 10:00 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, ROBERTO GAMILLA. At 10:20 a.m. Licensee CARRIE ACOSTA arrived at the facility. This annual had a specific emphasis on infection control practices and procedures.

Between 10:05 a.m.- 11 a.m., LPA 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.

KITCHEN: At 10:11 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:11 a.m., LPA observed a baby gate at the entrance into the kitchen. Staff removed the baby gate by the end of the visit. At 10:43 a.m., hot water measured at 112.1-degree Fahrenheit. LPA observed the fire extinguisher to be fully charged and last serviced on 10/30/2020.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restroom is relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 10:45 a.m., hot water measured at 116.0-degree Fahrenheit.

OUTDOOR SPACE: At 10:14 a.m., LPA observed the back patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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Document Has Been Signed on 09/16/2021 12:55 PM - It Cannot Be Edited


Created By: Emily Peraldi On 09/16/2021 at 11:54 AM
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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there were disinfectant wipes and alcohol accessible which poses an immediate health risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
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The Licensee has agreed to do the following:
1. The items were removed upon observation. Plan of Correction met.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Emily Peraldi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021


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: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489
VISIT DATE: 09/16/2021
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Continued from LIC 809.

Common Areas: At 10:12 a.m. LPA observed a daybed located in the living room area. Interviews with residents and Licensee revealed that the daybed is used as a couch for the most part but sometimes staff do take naps on the daybed. LPA spoke with Licensee in regard to the daybed and suggested getting a couch instead. LPA reminded Licensee that staff cannot sleep in the daybed that’s located in the living room area. There is a staff room that remains locked. At 10:15 a.m. LPA observed disinfectant wipes and alcohol in the common area. The staff removed these items upon observation. Medications and resident records are located in a locked file cabinet near the living room area.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day 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 facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

At 10:20 a.m., LPA conducted Infection Control mitigation module with Licensee.

The following deficiency was 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. Report issued and a copy of the report and appeal rights was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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