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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607861
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:57:28 PM

Document Has Been Signed on 02/07/2022 01:57 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:DREAM HOME FOR SENIORS, LLCFACILITY NUMBER:
197607861
ADMINISTRATOR:ZENAIDA & RICARDO VELASCOFACILITY TYPE:
740
ADDRESS:20743 CLARK STREETTELEPHONE:
(818) 835-9837
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 0DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Zenaida VelascoTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Elsie Campos and Ashley Smith arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA's met with Administrator Zenaida Velasco and explained the reason for the visit. The administrator advised that there are currently no residents in the facility.

The LPA's toured the physical plant areas inside and outside, with Zenaida Velasco at 9:56 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are (4) four bedrooms designated for resident use. Bedroom #2 and Bedroom #4 have a direct exit to the exterior. The facility is capable of furnishing each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Bedroom #3 leads to a hallway, which allows for access to Bedroom #5 and Bedroom #6; however, those two rooms designated for staff. There is an exterior door that leads to Bedroom #5 and Bedroom #6. Staff are aware that once they have residents in Bedroom #3, staff would need to enter their rooms through the exterior door.

RESTROOMS: There are (2) bathrooms designated for resident use. There is a bathroom designated for staff use only. Bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA's advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs prior to allowing resident admissions. Between 10:41 a.m. – 10:44 a.m., the LPA's measured the hot water temperature in (2) two out (3) three bathrooms. The hot water temperatures measured between 123.3 and 124.3 degrees Fahrenheit.

Continued on LIC 809-C.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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 02/07/2022 01:57 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/07/2022 at 12:09 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: DREAM HOME FOR SENIORS, LLC
FACILITY NUMBER: 197607861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the hot water registered above 120 degrees farenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/08/2022
Plan of Correction
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The adminsitrator agreed to do the following:
1. Adjust the water heater. Administrator adjusted during today's visit.
2. Complete a 5 day log of hot water temperature. Submit to CCL no later than 2/14/22.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2022 01:57 PM - It Cannot Be Edited


Created By: Elsie Campos On 02/07/2022 at 12:09 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: DREAM HOME FOR SENIORS, LLC
FACILITY NUMBER: 197607861

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 the fire extinguishers were purchased in 2019, which poses a potential health and safety risk to persons in care.
POC Due Date: 02/14/2022
Plan of Correction
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The administrator agreed to do the following:
Purchase or service fire extinguishers and submit proof to CCL no later than 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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022


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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: DREAM HOME FOR SENIORS, LLC
FACILITY NUMBER: 197607861
VISIT DATE: 02/07/2022
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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured at 124.1 degrees Fahrenheit at 10:39 a.m.

COMMON SPACES: The common spaces included the living room, dining area, activity room, entertainment room and office area. The LPA's observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. All were tested at 10:47 a.m. and observed to be operational. The fire extinguisher was observed to be full and last bought on 02/28/19. The LPA's observed required postings in the hallway in the living room.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Two storage sheds were observed locked which included PPE supplies and additional cleaning supplies. The LPA's observed a Laundry room which is located in an enclosed patio adjacent to the kitchen. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the laundry area cabinet. The laundry room was observed to be locked and inaccessible to residents. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA's spoke with the Administrator Zenaida Velasco regarding the facility’s infection control practices. The Administrator was advised that they need to have upon entry, a central entry point for symptom screening, temperature checks, and sanitation station. The LPA's also advised the Administrator to maintain a 30-day supply of Personal Protection Equipment (PPE). The Administrator requested additional N-95 masks. 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 does not have a confirmed case of COVID-19 at this time and the LPA's reviewed facility’s policies and procedures as it pertains to infection control. Lastly, the LPA's stated that they will send additional information via email in regard to signage to be posted around the facility.

The following deficiencies were 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. A copy of the report and appeal rights were provided via Email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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