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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 01/17/2024
Date Signed: 01/17/2024 04:12:37 PM

Document Has Been Signed on 01/17/2024 04:12 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
WOODLAND HILLS S.ASC, 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: 4DATE:
01/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Melina SerranoTIME COMPLETED:
12:43 PM
NARRATIVE
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During Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit regarding Complaint #31-AS-20240111081949, LPA Spaeth reviewed resident's files at 11:50 am until 12:30 pm, LPA observed documents were missing from two residents' files.

Based upon review of residents' records and upon Title 22 Regulations, the following deficiencies are substantiated (See 809-D page).
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 01/17/2024 04:12 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 01/17/2024 at 01:12 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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
87458(a)

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 87458 Medical Assessment (a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file documentation of a medical assessment, signed by a physician, made within the last year….This requirement is not met as evidenced by:
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Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth
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Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/26/2024
Section Cited
CCR87507(b)

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87507 Admissions Agreements (b) Admissions agreements shall be signed and dated,…by the resident. This requirement is not met as evidenced by:
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Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth
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Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files.
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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:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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