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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 08/07/2024
Date Signed: 08/08/2024 10:53:03 AM

Document Has Been Signed on 08/08/2024 10:53 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HUMBLE HAVEN RCFE IIFACILITY NUMBER:
197610008
ADMINISTRATOR/
DIRECTOR:		ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:John AllenveDeJesusTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 08/07/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit. LPA Melissa Spaeth was greeted by a caregiver. LPA Spaeth spoke to the Licensee, Nicole De Las Alas by phone and the Licensee arrived at 10:20 am. The Licensee stated they have sold the facility to another individual but did not know the status of the buyer's application with CCL. The Licensee also stated the two staff members working at the facility were hired by the new owner. The Licensee stated they had a personal appointment and had to leave the facility. The Licensee left at 11:05 am.

The facility is licensed as a Residential Care Facility for the Elderly (RCFE) to serve six residents of which six (6) may be non-ambulatory and one (1) may be bedridden. There is a hospice waiver for three residents. There are five residents living in the facility.

At 11:15 am, a former staff member arrived and stated they had purchased the facility as of May, 2024 and they had been a previous staff member of the facility. LPA Spaeth observed the previous staff member and the two caregivers who are currently working at the facility had received criminal record clearance.

LPA and the caregiver began the tour at 10:00 am until 11:00 am. LPA Spaeth observed the following:

Common areas – LPA observed the family room contained comfortable seating.

Dining Room/Kitchen Combination – LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food in the refrigerator. LPA Spaeth observed the kitchen knives and cleaning solutions were locked underneath the kitchen sink. The medications were safely locked in a kitchen cabinet.

Backyard- LPA observed comfortable seating located in a shaded area. The gate leading from the backyard to the front yard was not locked.

Continued on 809-C.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HUMBLE HAVEN RCFE II
FACILITY NUMBER: 197610008
VISIT DATE: 08/07/2024
NARRATIVE
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Resident Bedrooms – LPA observed the five residents’ rooms were neat and clean. The bedrooms contained a bed, linens, night stand, night lamp, chest of drawers and closet.

Bathrooms – The two bathrooms contained hand soap, paper towels, trash can, a slip resistant mat, and grab bars. LPA Spaeth tested the water temperature at 10:50 am in the resident’s bathroom and the water temperature was 126.6 degrees F.

Hallway Closet – The closet contained clean linen and PPE supplies.

Staff Room – The staff’s bedroom was locked.

Garage – The garage was locked and contained the washer, dryer, laundry detergent and an additional deep freeze filled with frozen meats and vegetables.

Smoke/Carbon Monoxide Detector- The detectors were tested at 11:00 am and were functional.

LPA reviewed the residents’ files at 1:00 pm until 1:30 pm. LPA reviewed the staff files at 2:00 pm until 2:30 pm and observed there were no staff files for the two caregivers working at the facility.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to the caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2024 at 01:35 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: 08/07/2024

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 LPA's observation during the tour of the facility, the licensee did not comply with the section cited above. The water temperature was tested in the resident's bathroom and was 126.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/07/2024
Plan of Correction
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During LPA's visit, the water temperature to the water heater was reduced. At 2:00 pm, LPA tested the water temperature in the resident's bathroom & observed the water temperature was 110.00 degrees F.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based upon LPA's observation, the licensee did not comply with the section cited above. The two caregivers working at the facility verbally confirmed they had not completed CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2024 at 01:39 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)2
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 2. If the educational hours/units are obtained through an accredited educational institution, documentation shall include a copy of a transcript or official grade slip showing a passing mark.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the required job training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.
Type B
Section Cited
CCR
87412(c)(2)(D)3
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 3. If the educational hours/units are obtained through continuing education, documentation shall include a transcript or official grade slip showing a passing mark, if applicable, or a Certificate of Completion.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the required job training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will forward proof the two caregivers have completed the required on the job training and send written confirmation to LPA Spaeth via email.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2024 at 01:44 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The licensee will send written proof the caregivers have completed the training. The Licensee will send the written proof to LPA Spaeth via email.

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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2024 at 01:47 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(4)(D)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (D) An explanation of the basic rules and precautions of medication assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.
Type B
Section Cited
HSC
1569.69(a)(4)(E)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (E) Information on medication forms and routes for medication taken by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will forward proof the two caregivers have completed the required training and send written confirmation to LPA Spaeth via email.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/07/2024 at 01:47 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(4)(F)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (F) A description of procedures for providing assistance with the self-administration of medications in and out of the facility, and information on the medication documentation system used in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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4
The Licensee will send written proof of the caregivers' completion of the above described training. The Licensee will send proof to LPA Spaeth via email.
Type B
Section Cited
HSC
1569.69(a)(4)(G)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (G) An explanation of guidelines for the proper storage, security, and documentation of centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above. The two caregivers have not completed the above-referenced training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
The Licensee will send written proof of the caregivers' completion of the above described training. The Licensee will send proof to LPA Spaeth via email.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 08/08/2024 10:53 AM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/08/2024 at 10:29 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements-General (c) All RCFE staff who assist residents with personal activities & annual training as specified in Health and Safety Code sections…(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the LPA's observations, the licensee did not comply with the section cited above. The two caregiers have not completed the CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2024
Plan of Correction
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2
3
4
The Licensee will send a copy of the caregiver's certificate of completion of the CPR and first aid training via email to LPA Spaeth
Type A
Section Cited
CCR
87411(f)
87411 Personnel Requirements-General (f) All personnel shall be in good health…Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician …A report shall be made of each screening, signed by the examining physician…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's observation the licensee did not comply with the section cited above. The two caregivers have not completed the health screening including the chest x-ray or an intradermal test which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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The Licensee will send the completed health screening paperwork for the two caregives to LPA Spaeth via email.
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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024


LIC809 (FAS) - (06/04)
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