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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609097
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:02:55 PM

Document Has Been Signed on 05/17/2022 04:02 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:THREE C'S CARE HOMEFACILITY NUMBER:
197609097
ADMINISTRATOR:LOPEZ, MILAGROSFACILITY TYPE:
740
ADDRESS:6447 BABCOCK AVENUETELEPHONE:
(818) 747-2212
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lea EbuengTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos 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 met with Staff Lea Ebueng and explained the reason for the visit. The LPA spoke to the Administrator over the phone Milagros Lopez and also explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with staff to ensure there are no health and safety hazards.

BEDROOMS: There are (3) three bedrooms designated for resident use. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

RESTROOMS: The LPA observed resident restrooms to be clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Restroom hot water measured between 131.3 and 132.0 degrees Fahrenheit between 2:00 p.m. and 2:06 p.m. The LPA advised staff to immediately adjust the water heater temperature to ensure compliance.



KITCHEN: The LPA observed the Kitchen oven, microwave, and dishwasher to be inoperable, and per the staff is not used. The facility has a 2nd working microwave. The administrator was advised that all kitchen appliances need to be in good repair and operable. The facility has a sufficient supply of perishable food and nonperishable food. Knives, medications, and chemicals were locked and inaccessible. The facilities laundry closet is located in the kitchen which was locked and inaccessible to residents at the time of the visit.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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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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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097
VISIT DATE: 05/17/2022
NARRATIVE
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COMMON AREAS: The common spaces included the living room and dining area. All areas were clean, sanitary and in good repair. The LPA observed required postings on the living room wall. One fire extinguisher was observed to be fully charged and last purchased on 3/29/22. Smoke detectors and Carbon Monoxide detectors are hardwired and interconnected, they were tested at 2:31 p.m. and confirmed to be operable at the time of the visit.

BACKYARD: The backyard does not have a covered outdoor area equipped with furniture for resident use. The LPA observed an old patio set in disrepair with a flat piece of sheet wood being used as tabletop. A shopping cart was observed propped against the driveway wall. The LPA also observed old walking assistance devices, an old metal bedframe and miscellaneous items in disrepair that could be thrown away. A resident was using an old wheelchair to sit under a shaded ledge in front of the garage which is not appropriate. There were no bodies of water noted. The garage is attached to the house but has been converted to a separate living space but is being used for PPE storage and has an additional refrigerator. The administrator was advised to clean the backyard so that it may be accessible for resident use and free of any debris or obstructions.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff Lea Ebueng regarding the facility’s infection control practices. 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 reviewed facility’s policies and procedures as it pertains to infection control.


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: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 05/17/2022 04:02 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 03:20 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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

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 temperatures read between 131.3 and 132.0 degrees Farenheit. which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Immediatley adjust the water temperature. POC met at time of the visit.
2. Submit a hot water temperature log for five (5) days with readings from all bathrooms and kitchen no later than the 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: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/17/2022 04:02 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 03:20 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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 LPA observed kitchen appliances in disrepair, patio furniture in disrepair with unsafe seating area which poses potential health and safety risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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The Licensee agreed to the following:
1. Replace kitchen appliances and or discard of inoperable appliances.
2. Submit proof to CCL of reapirs or replacement no later than the POC date.
Section Cited
Maintenance and Operation
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: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/17/2022 04:02 PM - It Cannot Be Edited


Created By: Elsie Campos On 05/17/2022 at 03:20 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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

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 LPA observed that live in staff did not have designated sleeping quarters and were sleeping on the couch in the common area living room which poses a potential personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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The Licensee agreed to the following:
1. Submit a plan of action to ensure staff sleep in designated sleeping areas only. Submit to CCLD no later than the 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: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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