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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609758
Report Date: 04/08/2025
Date Signed: 04/08/2025 12:03:08 PM

Document Has Been Signed on 04/08/2025 12:03 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DANIAS SENIOR HOMEFACILITY NUMBER:
197609758
ADMINISTRATOR/
DIRECTOR:		BAEZA, DANIA ELISABETHFACILITY TYPE:
740
ADDRESS:22331 COVELLO STTELEPHONE:
(747) 226-3342
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 4DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Dania Baeza, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs met with the Administrator and explained the reason for the visit.

At 9:40am LPAs conducted a physical plant tour and observed the following:

Facility is licensed for capacity of six (6) Non-Ambulatory of which one (1) may be Bedridden in room #1 or #2. Hospice waiver for four (4) residents is also approved.

LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher is located in the kitchen area and was last serviced on 01/24/2025. Facility maintains a temperature of 72°F. Medications, resident/staff files were kept in the kitchen cabinet and observed to be locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. There are four (4) bedrooms designated for residents’ use, and three (3) bathrooms. Facility has an awake staff. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 108.5°F. Laundry is located in the hallway. The washer/dryer appear to be in a good condition. Laundry supplies, chemicals and detergents are kept locked in the laundry room and inaccessible to residents in care.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758
VISIT DATE: 04/08/2025
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Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:45am they were tested and observed to be operational. At 10:55am, LPAs observed appropriate outdoor furniture, with a covered shaded area for the residents. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Between 11:00am to 12:00pm, LPAs reviewed records of four (4) residents and two (2) staff, and the following noted:

· One (1) out of four (4) residents had full bed rails however, no doctor's order was available. Per Administrator, Resident #1 (R1) was on hospice for a long period of time and due to the insurance not covering the hospice services the agency had to discharge R1. LPAs were informed that on 04/10/25, R1 will be admitted back on hospice and start receiving services again. LPAs explained that full bed rails are not permitted unless a resident is on hospice and if resident/family insists an exception can be submitted to CCL with all required documents.

LPAs collected Certificate of Liability Insurance and LIC500.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited on LIC809-D

Exit interview conducted. Appeal rights explained and a copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/08/2025 12:03 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/08/2025 at 11:27 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: DANIAS SENIOR HOME
FACILITY NUMBER: 197609758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and LPAs observation, the licensee did not comply with the section cited above by not obtaining a full bedrail doctor's order for R1 (who is not currently on hospice), which poses a potential health and safety risk to residents in care.
POC Due Date: 04/15/2025
Plan of Correction
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Administrator removed the full bed rails during time of visit and informed LPAs that the hospice agency had been already contacted and R1 is scheduled to be admitted on hospice as of 04/10/25. Administrator agreed to submit R1's new hospice
agreement 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
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