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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609306
Report Date: 01/04/2022
Date Signed: 01/04/2022 04:26:07 PM

Document Has Been Signed on 01/04/2022 04:26 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:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR:BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
01/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Elaine BoteTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-NP-20211230095404.

At 1:09 p.m. the LPA conducted a physical plant tour. At 1:21 p.m. the LPA observed unlocked medication in the refrigerator, at 1:21 p.m. accessible cleaning supplies were observed in the bathroom underneath the sink and at 1:30 p.m. it was communicated by staff that the facility had been without hot water for two days. The water heater was fixed during today’s visit. The administrator confirmed that they did not inform the department of this incident. During today’s visit the LPA discovered that Resident #1 (R1) was recently hospitalized for a fractured wrist due to a fall in the facility bathroom. This incident was also not reported to the department.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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
Document Has Been Signed on 01/04/2022 04:26 PM - It Cannot Be Edited


Created By: Elsie Campos On 01/04/2022 at 03:44 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2022
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:
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The Administrator agreed to do the following: Submit incident reports for each incident no later than 1/10/2022.
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Based on interview and record review, the licensee did not comply with the section cited above, as a report was not submitted regarding R1’s fall nor the lack of hot water, which poses a potential health and safety risk to residents in care.
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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: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/04/2022 04:26 PM - It Cannot Be Edited


Created By: Elsie Campos On 01/04/2022 at 03:58 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2022
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins .... toxic substances such.. cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Secure the items. The items were secured during today's visit.
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Based on observation, the licensee did not comply with the section cited above, as medications and cleaning supplies were accessible, which poses an immediate health and safety risk to residents in care.
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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: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2022


LIC809 (FAS) - (06/04)
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