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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606424
Report Date: 02/09/2024
Date Signed: 02/09/2024 02:37:33 PM

Document Has Been Signed on 02/09/2024 02:37 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:HAZELWOOD MIGHTY HOMESFACILITY NUMBER:
197606424
ADMINISTRATOR:ELIZABETH A. DAGOYFACILITY TYPE:
740
ADDRESS:1557 HAZELWOOD AVENUETELEPHONE:
(323) 257-1487
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 0DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Elizabeth Dagoy, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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At 11:10 AM Licensing Program Analysts (LPAs), Huma Rahimi, and Perchui Milena Khurshudyan conducted an unannounced annual inspection at the facility mentioned above. LPAs met with Staff Lucena Dagoy, and at 11:45 AM the Administrator Elizabeth A Dagoy arrived at the facility and LPAs explained the reason for the visit. At 12:10 PM, Physical tour was conducted with the Administrator and LPAs observed the following:

Censes: The current censes is 0.

Kitchen: At approximately, 12:13 PM LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. LPAs observed sharps to be locked and stored in a cabinet near the exit door to the back of the kitchen. LPAs observed toxins, cleaning solutions, and soap stored and locked underneath the kitchen cabinet sink.

Medications: The facility do not have any residents; therefore, no medications were observed. In the living room, the facility is having a chest drawer in which they keep the medications locked.

Bedrooms: The facility has four (4) bedrooms. One of the bedrooms is designated for live-in staff. LPAs observed the staff room to be free of hazard and locked. LPAs observed all bedrooms to be clean and clear from obstruction, properly furnished, sufficient lighting, appropriate bedding and linens. Trash cans observed to have attached lid.

Bathrooms: At 12:20 PM, LPAs observed the bathrooms to be clean and in good repair. LPAs observed the appropriate grab bars in and around the toilet and shower also non-skid mats are located in the shower area. The water temperature measured 119.2 degrees Fahrenheit. Hand towels and wash clothes are not shared



Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
VISIT DATE: 02/09/2024
NARRATIVE
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Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.

Smoke detectors/carbon monoxide. At 12:28 PM, the fire alarm system was tested and observed to be working, it is hard wired and interconnected. The carbon monoxide detector is located on the wall in the kitchen.

Outside areas: At 12:35 PM, LPAs observed the backyard and surrounding area of the facility to be clean and clear from debris. A covered canopy area with tables and chairs for lounging, the front porch area is shaded with chairs for lounging. A detached garage observed to be locked and currently used as storage. No bodies of water observed on the premises.



Laundry Room: LPAs observed the washing machines located outside in the back of the facility. LPAs observed to be clean and clear from obstruction. Laundry soap, toxins and cleaning supplies are stored outside on a shelf near the laundry machines, inaccessible to residents.

Between 1:00 PM to 1:30 PM, LPAs reviewed records of one (1) resident (R1) and two (2) staff.

LPAs reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters, and they are all responsible for reporting.

Additionally, upon request of the Certificate of Liability Insurance, the Administrator stated that they cancelled the insurance due to the financial hardship on or about July, 2023.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424
VISIT DATE: 02/09/2024
NARRATIVE
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LPA informed the Administrator to submit the following one (1) Death Report that occurred on:

· 01/14/24


· Certificate of Liability Insurance

Per the California Code of Regulations, Title 22, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/09/2024 02:37 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/09/2024 at 02:03 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: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)!1)A,B&D

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and the person.... .anh of the events specified in (A), (B) & (D)....
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviews conducted by LPAs the licensee did not comply with the section cited above by failing to notify CCLD regarding the death of R1 which occurred on 01/14/2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee shall ensure a written repot is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of one (1) incident for R1, shall be submitted to LPA by POC 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/09/2024 02:37 PM - It Cannot Be Edited


Created By: Huma Rahimi On 02/09/2024 at 02:16 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: HAZELWOOD MIGHTY HOMES
FACILITY NUMBER: 197606424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and request of the liability insurance the licensee did not comply with the section cited above in not having the liability insurance since July 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee shall ensure to purchase a liability insurance and a proof of purchase shall be submitted to LPA by POC 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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