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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:14:30 PM

Document Has Been Signed on 09/25/2024 03:14 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/
DIRECTOR:		ALAS, NICOLE DE LASFACILITY TYPE:
740
ADDRESS:37801 RUDALL AVE.TELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 5DATE:
09/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Malina Sorrano & Reyoldo SorranoTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the caregiver.

An Informal Meeting was conducted at the Woodland Hills Office on 9/17/2024 with the Licensee, Nicole De Las Alas. LPM Troy Agard discussed the deficiencies cited at the facility during an annual visit conducted on 08/07/2024. LPA Spaeth reviewed the deficiencies with the Licensee and informed the Licensee the deficiencies must be cleared by Tuesday, 9/24/2024.

Upon arrival, LPA explained the purpose of the visit was to review the residents' files and receive a copy of a staff member’s (S2) CPR/First Aid training certificate. LPA Spaeth received a copy during the visit

LPA toured the facility at 10:20 am until 10:55 am. At 10:45 am, LPA observed a bedridden resident was not in the designated bedridden room. At 11:00 am, LPA observed the auditory device on the front door and the exit doors to Rooms 2 and 5 were not working. LPA Spaeth reviewed the resident's files at 11:15 am until 12:00 pm. LPA observed five out of five residents' files were missing the I.D & Emergency Information form (LIC 601) and Personal Rights form. LPA also observed four out of the five residents are on hospice care. However the facility has an approved hospice waiver for three residents.

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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 09/25/2024 03:14 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/25/2024 at 12:10 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87202(a)(2)

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87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2) Bedridden persons. This requirement is not met as evidenced by
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Administrator stated that R1 will be transferred to bedroom #5 by 9/26/2024 and will send a snapshot of the room change.
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The Licensee failed to follow Title 22 Regulations regarding approved fire clearance, by placing bedridden resident R1 to the room that had no bedridden fire clearance. This poses an immediate health and safety risk to residents in care.
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Type A
09/26/2024
Section Cited
CCR87705(j)

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87705 Care of Persons with Dementia (j) The licensee shall have an auditory device…to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
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The Administrator will ensure the auditory devices at the front door, Room 2 and Room 5 are properly working. The Administrator will notify LPA Spaeth when the devices are repaired.
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Due to LPA's observations, the Licensee failed to ensure the auditory devices were working at the front door and exit doors in Rooms 2 and 5
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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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2024 03:14 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/25/2024 at 12:37 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87632(a)(1)

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87632 Hospice Care Waiver (a) In order to accept or retain terminally ill residents & permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice waiver …(1) Specification of the maximum number of terminally ill resident which the facility wants to have….
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Administrator stated they will send a hospice waiver increase to the Woodland Hills South office.
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This is evidenced by: The facility has an approved hospice waiver for three residents. However, LPA observed there are four out of five residents who are on hospice.
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Type B
09/27/2024
Section Cited
CCR87506(b)(8)

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87506 Resident Records (b) each resident’s record shall contain….(8) names, address, & telephone numbers of resident’s representative….. This is evidenced by:
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The Administrator stated they will obtain the completed/signed forms and forward copies to LPA Spaeth via email.
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LPA Spaeth observed the five residents' files did not contain a completed LIC 605 I.D. & Emergency Information and LIC 613C Personal Rights documents
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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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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