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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603599
Report Date: 10/15/2024
Date Signed: 10/15/2024 12:50:53 PM

Document Has Been Signed on 10/15/2024 12:50 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BEST ELDER CAREFACILITY NUMBER:
197603599
ADMINISTRATOR/
DIRECTOR:		IGID, FABIOLAFACILITY TYPE:
740
ADDRESS:37620 SIMI STREETTELEPHONE:
(661) 878-8105
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gemma WanawanTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 10/15/2024 at approximately 10:00 am, Licensing Program Analysts (LPAs) Angelica Segovia and Gina Saucedo met with caregiver Gemma Wanawan for a One (1) Year Required, Unannounced visit for this facility. LPA explained the reason for the visit.

LPA asked for census, staff, and resident files…. LPAs conducted a physical plant tour at approximately 11:00 am and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with five (5) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for one (1) resident.

Required postings such as Personal Rights and Ombudsman were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Both living and dining rooms are neat, clean, and organized. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. Fire extinguisher located in the kitchen and last inspected on 08/29/24. Additional required postings were observed aside the kitchen such as: Yes poster, Fire Drill and Disaster Plan.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a kitchen drawer and inaccessible to residents. Cleaning solutions are kept locked in a cabinet under the sink. Stove observed to be working and in proper condition.

(continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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Document Has Been Signed on 10/15/2024 12:50 PM - It Cannot Be Edited


Created By: Angelica Segovia On 10/15/2024 at 12:34 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: BEST ELDER CARE
FACILITY NUMBER: 197603599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

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 in 2 out of 2 objects which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee will ensure that proper lighting is available both in resident's rooms and bathrooms.
Type B
Section Cited
CCR
87705(k)
Care of Persons with Dementia
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates:

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 in one out of one objects which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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Licensee will ensure that the one door lock is fixed and is properly functioning.
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:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BEST ELDER CARE
FACILITY NUMBER: 197603599
VISIT DATE: 10/15/2024
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The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in the facility.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

The Garage can be accessed from the inside of the facility. The garage is equipped with an extra refrigerator and fully stocked with food. Laundry room is located along the bedroom hallway leading to the garage. Laundry detergents, cleaning agents, and other toxins are stored in a locked cabinet in the laundry area inaccessible to residents.

The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the toilets and showers. The hot water temperature was measured at a range of 119.1°F. Towels and washcloths are not shared. Sufficient availability of clean linen stored in hallway cabinet.

Medications: LPAs observed medication in the bedroom hallway cabinet to be locked and inaccessible to residents. Medication usage recorded and stored properly. LPAs along with Caregiver Wanawan conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to: bandages, scissors, digital thermometer, tweezer, and manual.

Resident records: LPAs conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPAs conducted a complete file review of staff records. Staff records appeared to be complete and updated.

An exit interview was conducted, two (2) citations were issued, appeals rights and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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