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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 10/12/2023
Date Signed: 10/12/2023 01:12:31 PM

Document Has Been Signed on 10/12/2023 01:12 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:
10/12/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sylvia Jackson, Administrator TIME COMPLETED:
01:40 PM
NARRATIVE
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At 09:30am, Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, Leslie Ngo-Castaneda and Gina Saucedo conducted an unannounced Case Management Visit. The team met with the Administrator and explained the reason for the visit.

On 12/01/22, an informal meeting was held at the Regional Office (RO) with the Administrator and concerns from Complaint #31-AS-20220210102557 were addressed. At that time, Regional Manager (RM) and Licensing Program Manager (LPM) advised the Administrator to conduct thorough pre-admission appraisals and complete staff training on Basic Services.

The purpose of todays visit is to review all resident and staff files for an accuracy. Team was informed that the facility currently has five (5) residents. Facility also has three (3) staff members, but during today's visit the team observed one staff member (S1) on duty. The team checked the Licensing Information System (LIC) and observed that S1 is associated with this facility and the fingerprints are cleared.

Resident Files: At 9:45am team conducted resident and staff records review. The following was observed. Five (5) out of five (5) resident file were either not available and or incomplete. Files were missing TB test results for four (4) out of five (5) residents, ID Emergency Sheets, and personal rights. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report.

Staff Files: Administrator stated that the facility currently has four (4) staff members. However, none of the staff members had a facility file available for review.

Therefore, the following deficiencies are issued per CA Code of Regulations, Title 22. See LIC809-D.


Exit interviewed discussed, appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 10/12/2023 01:12 PM - It Cannot Be Edited


Created By: Angela Panushkina On 10/12/2023 at 12:33 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
87506(a)

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident...

This requirement is not met as evidenced by:
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Licensee agreed to complete five (5) out of five (5) resident files.
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Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/19/2023
Section Cited
CCR87412(a)

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87412 Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
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Licensee agreed to have a individual file for each staff member along with the training certificate.
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Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide S1's facility records. LPA was informed that S1 got hired in Fabruary 2023 and no file was completed. This poses/posed a potential health, safety or personal rights risk to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023


LIC809 (FAS) - (06/04)
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