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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609931
Report Date: 12/01/2021
Date Signed: 12/01/2021 12:05:37 PM

Document Has Been Signed on 12/01/2021 12:05 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:KAREN'S BOARD AND CARE, INCFACILITY NUMBER:
197609931
ADMINISTRATOR:ZINKOFSKY, CLARITAFACILITY TYPE:
740
ADDRESS:17231 TUBA STREETTELEPHONE:
(818) 216-3271
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Clarita Zinkofsky TIME COMPLETED:
12:20 PM
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At 9:25 a.m. Licensing Program Analyst Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. Infection control: Upon arrival, LPA observed covid-19 signage posted outside on the front door and along the main entrance. Upon entrance, LPA was not screened by staff #1 and was not asked any infection control questions. Additionally, staff #1 did not take LPA’s temperature. When LPA asked the staff what their screening procedure for visitors was, the staff stated they just made sure the visitor has a mask on. No more information was provided to LPA.

At 9:40 a.m., a tour of the physical plant was conducted. Smoke alarms were tested at 10:00 a.m. and function properly. The fire extinguisher was last serviced on 4/19/21. Kitchen: The kitchen appears clean, the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility, all of which were properly stored and labeled. Medications were locked in a cabinet near the kitchen. At 10:17 a.m., knives and detergents were observed to be accessible to residents in care. Staff immediately proceeded to properly store these items. Bedrooms: There were six (6) bedrooms designated for residents' use and one (1) staff bedroom. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There are three (3) bathrooms, and all are designated for residents' use. Bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 117.8 degrees Fahrenheit. Some cleaning supplies were kept in a locked pantry. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. There was an outdoor pool in the backyard, which is kept locked and inaccessible to residents. Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report. Appeal rights issued. Report delivered and exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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 12/01/2021 12:05 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 12/01/2021 at 11:16 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: KAREN'S BOARD AND CARE, INC
FACILITY NUMBER: 197609931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above due to the staff not following the infection control mitigation plan which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/03/2021
Section Cited

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(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above due to knives and cleaning supplies being accessible to residents in care which poses an immediate 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:Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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