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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:37:47 PM

Document Has Been Signed on 12/01/2022 04:37 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:HEPZEBAH HOUSEFACILITY NUMBER:
197609871
ADMINISTRATOR:JACKSON, SYLVIAFACILITY TYPE:
740
ADDRESS:22230 VANOWEN STTELEPHONE:
(310) 213-4927
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Sylvia JacksonTIME COMPLETED:
04:42 PM
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NCC changed to an Informal Conference

At 3:30 p.m. on 12/01/2022, Licensing Program Analyst (LPA) Nicholas Reed, Licensing Program Manager (LPM) Cassandra Harris, Regional Manager (RM) Angela Kendrick, and Licensee Sylvia Jackson held an Non-Compliance Conference. Licensee was given the opportunity to review the Community Care Licensing (CCL) file for Hepzebah House, containing licensing reports for the past three years.

Regional Manager (RM) Angela Kendrick explained the purpose of the non-compliance conference and the administrative process.

Today's conference primarily addresses concerns from Complaint #31-AS-20220210102557 in which the allegation "resident was neglected while living at the facility" was substantiated. A resident arrived to the facility on 11/14/2020 in poor condition. A preplacement appraisal was not conducted properly, and the resident was admitted to the hospital on 11/23/2022 with unstageable pressure injuries.

Community Care Licensing issued the following deficiencies:
87464(f)(1) Basic Services

Licensee Sylvia Jackson submitted a first level appeal of the substantiation on 11/28/2022. Licensee stated the resident was rotated every 2 hours and the best possible care was provided for the resident.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
VISIT DATE: 12/01/2022
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Community Care Licensing issued the following deficiencies during a Case Management visit on 02/11/2022:
87355(a) Criminal Background Clearance
87463(c) Reappraisals
87458(a) Medical Assessment
All staff now maintain current criminal background clearances.

Licensee Sylvia noted the difficulty with the preadmission process, stating the resident was admitted "too soon" and had many impressions and red marks on their body. Licensee believed the resident came directly from the hospital. The licensee trusted the referral agent. The resident was able to rotate independently. Licensee recalls the resident was admitted for approximately 5 days when they were noticed unresponsive in the morning.

RM and LPM advised to conduct thorough pre-admission appraisals. After consideration, RM opted that the meeting be changed to an Informal Conference between LPM, LPA, and Licensee.

LPM suggested a TSP referral for the facility. LPA will visit the facility within two weeks. LPM will review the complaint. LPA to amend the LIC 9099s from 11/1/2022 and 11/18/2022 to Unsubstantiated and create a Case Management visit to substantiate the allegation that the licensee should not have admitted the resident. LPA will also review resident records and staff trainings.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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