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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 02/09/2024
Date Signed: 02/09/2024 02:50:26 PM

Document Has Been Signed on 02/09/2024 02:50 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:KAREN'S SENIORS CARE HOME, INC.FACILITY NUMBER:
197609932
ADMINISTRATOR:ZINKOFSKY, BRANDONFACILITY TYPE:
740
ADDRESS:17610 HAYNES STREETTELEPHONE:
(818) 205-3820
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 5DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Brandon ZinkofskyTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual inspection. Upon arrival LPA met with Administrator Brandon Zinkofsky and explained the reason for the visit.

At approximately 11:10am, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and  last serviced in Jan 20, 2024.

 LPA observed Kitchen to be inaccessible to residents at this time. The kitchen appeared to be clean and the appliances and fixtures functional. Properly labeled medications and sharp objects were observed to be locked in a cabinet to the right of the fridge.  LPA observed a sufficient amount of perishable food stored in the fridge and non-perishable food  properly stored in a pantry inside of the laundry room on the exterior of the kitchen.Laundry area  located between living room and kitchen. LPA observed this room to be inaccessible to residents at this time. Cleaning supplies and detergents were observed locked in a cabinet below the water tank.

There were (7) bedrooms total with (1) bedroom designated for staff use, which was located next to the kitchen. LPA observed staff room to be  empty at this time. All bedrooms for clients use were properly furnished and had appropriate bedding and linens. At approximately 11:40am, LPA observed (4) residents sleeping in their bedrooms.

There were two bathrooms designated for resident use. Both bathrooms were clean, properly supplied and had functional fixtures. At 11:15am  Hot water temperature was measured at 123 degrees Fahrenheit. Administrator adjusted the temperature during the visit.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 02/09/2024 02:50 PM - It Cannot Be Edited


Created By: Brian Balisi On 02/09/2024 at 01:56 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one out of two bathrooms inspected the water temperature was measured above 120 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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During the inspection, the Administrator lowered the water temperature. Administrator also agreed to send LPA a temperature log for the next five (5) days and send the log to LPA via e-mail by EOD 02/14/2024.
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as R1 was admitted to the facility as total care and an exception is not on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2024
Plan of Correction
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Licensee agreed to submit a statment of understanding of regulation 87615(a) and obtain a new LIC 602 and submit to CCLD via email by COB 02/12/2024
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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


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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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
VISIT DATE: 02/09/2024
NARRATIVE
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Common Areas:  These included the living rooms and dining areas. The common areas were properly furnished and appeared to be relatively clean at this time. At approximately 12:15pm, LPA observed resident eating lunch at dining table.

Surrounding Grounds: LPA observed  shaded patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe any obstructions to emergency exits at this time. There is a detached garage located on the property. LPA observed garage to be used for storage of unused furniture, medical supplies and decorations.

Records review began at 12:00pm, SIX (6)  resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Records review revealed on 1/23/2023, Resident 1 (R1) was admitted into the facility and physician's report dated 01/18/2023, lists R1 as having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain the resident with a prohibited health condition. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time.

During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease. The facility has not had a confirmed case of a communicable disease at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate at this time.

Medications review began at approximately 2:00pm The medications are centrally stored in a locked cabinet to the right of the fridge and inaccessible to residents in care. Medications were observed to be properly documented on the centrally stored medications and destruction record at this time
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: KAREN'S SENIORS CARE HOME, INC.
FACILITY NUMBER: 197609932
VISIT DATE: 02/09/2024
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Continued from 809-C

Between 11am - 03:00pm the LPA interviewed four (4) staff members and one (1) resident.
 
LPA obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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