197610009-2-28-2023-29-AS-SURA-CPGV3M-20230228150459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610009
Report Date: 02/28/2023
Date Signed: 02/28/2023 03:06:11 PM

Document Has Been Signed on 02/28/2023 03:06 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TEESDALE VILLA RCFE		FACILITY NUMBER:	197610009
ADMINISTRATOR:	GUEVARRA, CORAZON HALILI		FACILITY TYPE:	740
ADDRESS:	7663 TEESDALE AVENUE		TELEPHONE:	(818) 356-5152
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 3	DATE:	02/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Corazon Guevarra		TIME COMPLETED:	03:10 PM

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On 02/28/2023, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 1:45 p.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena was greeted by staff, and staff contacted the Administrator Corazon Guevarra via telephone. The LPA spoke with the Administrator, and explained the reason for the visit. Administrator stated that they would arrive shortly.

At 2:15 p.m., LPA Urena and Administrator conducted a tour of the inside and outside the physical plant facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition.

Kitchen: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. Toxic materials are stored in a cabinet in the laundry room. The room was locked at the time of inspection.

Bedrooms: LPA Urena observed two residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean, and in good condition. Extra linens are stored in the laundry room.

Bathrooms: Two bathrooms were observed. One for staff and one for residents. Bathrooms appeared clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products was available.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TEESDALE VILLA RCFE	FACILITY NUMBER: 197610009
	VISIT DATE: 02/28/2023

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Outdoor Space: Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked. During a physical plant tour, it was observed that chemicals were dispersed throughout the outdoor area, which were not locked at the time of the visit. Car: bond chemicals, cleaners, paint spray cans were left on the open shelves within reach of residents. The passages were observed to have many articles that make the passage unsafe for residents. This poses an immediate health and safety risk to residents in care.

Infection Control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. The report was reviewed with Administrator Corazon Guevarra, signatures were obtained, and a copy of the report and Appeal Rights were issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2023 03:06 PM - It Cannot Be Edited

Created By: Sandra Urena On 02/28/2023 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TEESDALE VILLA RCFE	FACILITY NUMBER: 197610009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2023 Section Cited	1 2 3 4 5 6 7	87705(f)(2) Toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants are inaccessible. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above during a physical plant tour, it was observed chemicals dispersed throughout the outdoor area, not locked at the time of the visit:chemicals, cleaners, paint... This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Sandra Urena

LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023

LIC809 (FAS) - (06/04)

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