<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606838
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:09:40 AM

Document Has Been Signed on 11/02/2022 11:09 AM - 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TWIN PALMSFACILITY NUMBER:
197606838
ADMINISTRATOR:JOHN MALLONFACILITY TYPE:
740
ADDRESS:19929 SEPTO STREETTELEPHONE:
(818) 773-9291
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 5DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Art Montalvo TIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/02/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and the purpose of the visit was explained. LPA contacted administrator and explained the purpose of today's visit.

A physical plant tour was conducted at 10:10 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet. Chemicals were observed under the kitchen area and were unlocked. Staff immediately removed the chemicals and stored them in the garage. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 10:31a.m. and appear to be functional. Fire extinguishers were observed throughout the facility and are charged. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 72 F. Laundry area is located near the kitchen area and. Laundry chemicals are kept locked inside the cabinet. Resident Rooms: Facility has six (6) bedrooms of which one is designated for staff use. Facility has two live-in staff. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 116.7 F, which is in regulation. Grab bars and non-skid were observed. Cleaning chemicals were observed under the bathroom sink adjacent to room number three (3). (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838
VISIT DATE: 11/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Garage: There is a garage attached the the house that is accessible through the kitchen. Garage is kept locked and is used for storage, chemicals storage, and contains two fridges with additional food. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a pool that is drained and contains no water. Pool has a gate that is kept locked.

Deficiency cited on 809-D. Exit interview conducted. Report signed and delivered. Appeal rights issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/02/2022 11:09 AM - It Cannot Be Edited


Created By: Joscelyn Martinez On 11/02/2022 at 10:42 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TWIN PALMS
FACILITY NUMBER: 197606838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705(f)(2) Care of Persons with Dementia
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:
1
2
3
4
5
6
7
Cleaning chemicals were removed during the inspection and stored in the garage that is locked. Licensee is to conduct training to all staff on how to properly store and maintain cleaning chemicals inaccessible to residents in care. Training is to be submitted by 11/04/22.
8
9
10
11
12
13
14
Based on observation, staff did not ensure that cleaning chemicals were inaccessible to residents in care which poses an immediate hazard to the health, safe and personal rights to the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3