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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609931
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:53:44 AM

Document Has Been Signed on 12/12/2022 11:53 AM - 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:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Clarita Zinkofsky & Brandon Zinkofsky TIME COMPLETED:
12:00 PM
NARRATIVE
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On 12/12/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and later me with administrator Clarita Zinkofsky and Brandon Zinkofsky and the purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet. Chemicals are locked and stored in the laundry area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:11 a.m. and appear to be functional. Fire extinguishers were observed throughout the facility and are charged with a service date of 01/17/22. Common Areas: All common areas were observed to be clean and properly furnished. Laundry area is located in a passageway near the kitchen . Laundry chemicals are kept locked in the cabinet area. Resident Rooms: Facility has seven (7) bedrooms of which one is designated for staff use. All resident’s bedrooms are for private use and facility has two live-in staff. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which one is designated for staff and visitor’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 120 F, which is in regulation. Grab bars and non-skid mats were observed. (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: KAREN'S BOARD AND CARE, INC
FACILITY NUMBER: 197609931
VISIT DATE: 12/12/2022
NARRATIVE
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Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a shed use for additional storage that is locked and inaccessible to residents. There is a body of water that is gated and locked making it inaccessible to residents in care.

There was one caregiver working in the facility who's first work day was today, 12/12/22. Caregiver is not associated to the facility. LPA informed administrator caregiver can not work with residents until they receive clearance. Civil Penalties issued.

Deficiency cited on 809-D . Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2022
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Document Has Been Signed on 12/12/2022 11:53 AM - It Cannot Be Edited


Created By: Joscelyn Martinez On 12/12/2022 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: KAREN'S BOARD AND CARE, INC
FACILITY NUMBER: 197609931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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87355 (e)(1) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or..
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This requirement is not met as evidenced by:

LPA observed staff assisting residents in the bedroom. Per administrator, today is staff's first day and has not been cleared to work at the facility.
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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:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


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