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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 08/11/2021
Date Signed: 08/11/2021 12:39:49 PM

Document Has Been Signed on 08/11/2021 12:39 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:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR:ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Nicole Alas - AdministratorTIME COMPLETED:
12:55 PM
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At 9:53 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz, Angela Panushkina conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by staff who granted access to the home. This is a 6 bedroom, 2 bathroom single story facility. LPA met with Administrator Nicole Alas and a physical tour was conducted at 10:01 a.m. and observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/13/2021) to make sure licensee was following current infection control recommendations. Upon arrival, staff took LPAs temperatures and was asked to sign-in the visitors log but was not asked any infection control questions. Proper signage was observed inside along the hallway and in the restrooms however signage posted outside was observed to be incomplete. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPAs advised the administrator to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. Food Inspection: 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. At 10:03 a.m. sharps were observed to be accessible to residents. Administrator went ahead and purchased a toolbox with a lock to store and lock sharps. A receipt of purchase was obtained. Smoke detectors/carbon monoxide are dual and were observed to be operational throughout the facility. Resident rooms: There are 5 bedrooms designated for resident use and have sufficient lighting. One bedroom is designated for live-in staff. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Auditory alarms are placed on each door. The facility has dementia residents in care. Bathrooms: The hot water temperature measured at 120.3F. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene. At 10:06 a.m. LPA observed cleaning products/chemicals accessible to residents.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 08/11/2021
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The garage is attached to the home and was observed to be accessible to residents. At 10:10 a.m. LPA observed cleaning products/chemicals accessible to residents. Laundry service: There is enough linen available to change weekly or more if need. Medications are in a centrally stored and locked. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water.

Deficiencies and Civil penalties were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report.
Appeal rights issued.
Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2021 12:39 PM - It Cannot Be Edited


Created By: Melissa Ruiz On 08/11/2021 at 12:02 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: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which team observed cleaning chemicals to be accesible to residents located in both the resident restroom and garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2021
Plan of Correction
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Administrator has agreed to store and lock all cleaning supplies. Administrator has agreed to provide in house training to all staff on the importance of maintaining cleaning supplies inaccessible to residents in care. While LPA team was present, the administrator purchased a lock for the garage door to keep chemicals and cleaning supplies locked. LPA obtained a copy of the receipt. Administrator will provide proof of corrections by submitting pictures of the lock placed and documentation for the staff in-house training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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