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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610008
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:27:53 PM

Document Has Been Signed on 07/02/2025 04:27 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: 4DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jennifer Bihasa, Jasmin Bihas & Joselito BihasaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 07/02/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit. LPA Melissa Spaeth was greeted by the live in caregivers. The caregivers called the Licensee, Nicole De Las Alas and informed her LPA was present at the facility. The facility is licensed to serve six (6) non-ambulatory residents of which one (1) may be bedridden. There is a hospice waiver for three residents.

LPA and the caregivers toured the facility at 9:40 am until 10:20 am.

Kitchen - LPA observed a two-day supply of perishable foods and a seven-day supply of non-perishable food items. LPA observed a kitchen drawer was unlocked and contained a resident's medication. At 10:10 am, LPA instructed the caregiver to remove the medication. LPA observed the caregiver locked the medications in the medication cabinet. LPA observed the cleaning supplies were locked underneath the kitchen sink. The knives were locked in a drawer.

Resident Bedrooms – The bedrooms contained a bed, linens, night stand, night lamp, chest of drawers and closet.

Staff Room – At 9:55 am, LPA observed the staff’s bedroom was not locked and a staff member's medication was sitting out and not locked in a secure location.

Continued on 809_C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/02/2025
NARRATIVE
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Bathrooms – The two bathrooms contained hand soap, paper towels, trash can, a slip resistant mat, and grab bars.

Water Temperature - LPA Spaeth tested the water temperature at 10:50 am and the water temperature was 123 degrees F. The caregiver adjusted the water temperature. LPA again tested the water temperature at 11:13 am and the temperature was 118 degrees F.

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

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 11:10 am and were functional.

LPA reviewed the residents’ files at 11:30 until 11:50 am. LPA observed the Admissions Agreement and Appraisal & Needs Service Plan were missing from R1's file. LPA reviewed the staff files at 11:50 am until 12:15 pm. The staff files were missing the health screening documentation.

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.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/02/2025 04:27 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/02/2025 at 01:59 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations of staff files, the licensee did not comply with the section cited above. The caregivers did not receive training when they began working at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Licensee will send a document stating the date the three staff members have completed the training. The Licensee will send the document to LPA Spaeth via email.
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations of staff files, the licensee did not comply with the section cited above. The caregivers did not receive training when they began working at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Licensee will send a document stating the date the three staff members have completed the training. The Licensee will send the document 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/02/2025 04:27 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/02/2025 at 01:59 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of the resident's file, the licensee did not comply with the section cited above in one out of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Administrator will send a copy of the signed Admissions Agreement for resident 1 (R!) to LPA Spaeth via email.
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of the resident's file, the licensee did not comply with the section cited above in one out of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Administrator will send a copy of the appraisal/needs assessment for resident 1 (R!) 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 07/02/2025 04:27 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/02/2025 at 01:59 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(e)
Care of Persons with Dementia
(e) Licensees that use delayed egress devices on exterior doors and perimeter fence gates shall meet the following initial and continuing requirements:

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 in two out of four egress devices which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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During LPA's visit, LPA observed a caregiver activated the egress device to the back door of the facility and replaced the broken egress device in the master bedroom (room 5)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance & operation (e) Water supplies….shall be maintained..(2) Faucets used by residents for personal care…shall deliver hot water. Hot water temperature controls shall be …105 degree F (41 degree C) and not more than 120 degree F …

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 water temperature was 123 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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During LPA's visit, the staff member adjusted the hot water temperature. LPA tested the water at 11:13 am and observed the temperature was 118 degreees F
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 07/02/2025 04:27 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 07/02/2025 at 02:42 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: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications… (2) Centrally stored medicines shall be kept in a safe and locked place…

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed a resident's medications were not locked and the staff medications were not locked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2025
Plan of Correction
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3
4
During LPA's visit, LPA observed the resident's medications and the staff medications were safely locked.
Type B
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 not more than six (6) months prior to or seven (7) days after employment or licensure.ir duties…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's review of staff records, the licensee did not comply with the section cited above. Three staff members have not completed a health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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2
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The Licensee will send the Health Screening Report (LIC 503) for the three staff members via email to LPA Spaeth
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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