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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601489
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:24:48 PM

Document Has Been Signed on 11/02/2023 02:24 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: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:
11/02/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Carrie Acosta, LicenseeTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/20/2023. At 9:50 a.m., the LPA met with staff and explained the reason for the visit. At 10:20 a.m., the Licensee arrived at the facility.

At 10:10 a.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards.

Starting at 10:11 a.m., the LPA conducted interviews with two (2) out of four (4) residents and two (2) staff.

RECORD REVIEWS: Between 10:35 a.m. and 11:47 a.m., the LPA conducted a file review for all residents and staff regularly scheduled. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. The LPA was unable to identify the completed twenty (20) hours of annual training for staff. The LPA had several conversations with the Licensee with the goal of providing education in regard to staff training. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Two (2) out of four (4) residents require updated appraisals/needs and service plan. Additionally, the LPA requested updated copy of valid liability insurance and Facility Emergency Plan.
Between 1:20 p.m. and 1:50 p.m., the LPA conducted a review of medication and medication documentation with staff for four (4) out of four (4) residents and observed that all medications were properly documented.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Licensee was made aware that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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 11/02/2023 02:24 PM - It Cannot Be Edited


Created By: Emily Peraldi On 11/02/2023 at 02:08 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE
FACILITY NUMBER: 197601489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as staff did not have the required training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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The Licensee said that all staff will complete required annual training, including herself by due date.
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: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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