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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 08/08/2022
Date Signed: 08/08/2022 12:39:39 PM

Document Has Been Signed on 08/08/2022 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: 5DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shella Villar, DesigneeTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Shira Stamps met with designee Shella Villar for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:30am and was greeted by caregiver Shella Villar. The Administrator was contacted at 10:40am, and LPA spoke to the Administrator and informed her of the purpose of the visit. The Administrator was out of town over 45 minutes away, and designated caregiver Shella to sign the report. One (1) resident was observed in the living room resting. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting.

A tour of the physical plant was conducted with the Designee at 10:53 am. The facility has six (6) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is Fire Cleared for five (5) non-ambulatory and one (1) bedridden.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize/wash hands.

Food Inspection
LPA conducted tour of the kitchen around 10:55 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed a child squeeze lock on the cabinet under the kitchen sink. The cabinet obtained three (3) bottles of chemicals/ cleaning solutions and disposable needles. The Designee immediately locked the hazardous items in the garage. LPA observed all knives and sharp object being locked and inaccessible to residents in care in the locked hallway closet along with the resident’s medications. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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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: 08/08/2022
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Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:15 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 09/15/21.

Laundry/Garage
LPA observed the garage to be attached to the facility and currently being used for the laundry room, extra food storage, chemicals, and general storage. The garage remains locked at all times.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational.

Bathrooms
At 11:11am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 11:35am and measured within regulation at 115.0 degrees F.

Physical environment
LPA toured the outside area of the facility at 11:15pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Administrative: LPA collected the LIC.500 and resident roster. Annual fee is due 8/26/22. LPA reviewed resident record for room #4 to ensure resident is non-ambulatory and verified with physician report. Infection control plan has not been received, and LPA informed the Administrator to send the plan.


An exit interview was conducted over the phone with the Administrator. Citation issued, and appeal rights and copy of this report was given for the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2022 12:39 PM - It Cannot Be Edited


Created By: Shira Stamps On 08/08/2022 at 11:53 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: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 (f)(2) Care of Persons with Dementia 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 in that three (3) bottles of chemicals and disposable needles were accessible under the kitchen sink that did not have a proper lock, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2022
Plan of Correction
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The Licensee shall provide in house training to all staff reviewing the regulation section cited above, and provide signatures of all staff members that completed the training to the LPA by the POC due date.
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:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022


LIC809 (FAS) - (06/04)
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