<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610333
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:30:01 PM

Document Has Been Signed on 05/17/2024 03:30 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
Lookup Error,
, CA
FACILITY NAME:HUMBLE HAVEN RCFE IVFACILITY NUMBER:
197610333
ADMINISTRATOR/
DIRECTOR:		DE LAS ALAS, NICOLEFACILITY TYPE:
740
ADDRESS:4036 TOURNAMENT DRIVETELEPHONE:
(707) 688-5606
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 6DATE:
05/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Jasmin, Joselito & Jennifer BihasaTIME VISIT/
INSPECTION COMPLETED:
01:59 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/17/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregivers Jasmin, Joselito, and Jennifer Bihasa and explained the purpose of the visit.

During a complaint investigation visit on 05/17/24, LPA Dabuet was informed that (4) out of (6) residents are in hospice care. The residents on hospice are (R1), (R2), (R4), and (R5). The facility is approved by the Community Care Licensing Department (CCLD) for (3) hospice residents. The licensee shall not operate a facility beyond the conditions and limitations specified on the license.

On 05/17/24, between 11:15 am - 11:35 am, LPA Dabuet reviewed staff files and observed that staff #2 and #3 had no current First Aid/CPR certificate for training. (S2-S3) communicated that they have not renewed their required training for First Aid/CPR.

Based on interviews, observation, and record reviews the licensee violated Title 22 Regulations. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Jasmin Bihasa.


Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/17/2024 03:30 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 05/17/2024 at 01:14 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
,
, CA

FACILITY NAME: HUMBLE HAVEN RCFE IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2024
Section Cited
CCR
87204(a)

1
2
3
4
5
6
7
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to request for hospice waiver increase request to CCLD by correction date 05/31/24 understands that it is their responsibility to follow up on waiver requests and hospice residents should not reside at the facility until a hospice waiver is granted by CCL.
8
9
10
11
12
13
14
Based on [(observation) (interview) (record review)], the licensee did not comply with the section. The facility is approved for (3) hospice waiver and is now operating with (4) hospice residents beyond the conditions and limitations specified on the license. This violation which poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Plan of correction must be submitted by 05/31/24 to ernand.dabuet@dss.ca.gov
Type B
05/31/2024
Section Cited
CCR87411(c)(1)

1
2
3
4
5
6
7
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.(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:
1
2
3
4
5
6
7
Licensee/Administrator will ensure that all staff involved with resident's daily care must have a current First Aid/CPR training. Proof of correction must be sent to by POC due date: 05/31/24 to ernand.dabuet.@dss.ca.gov
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above . LPA identified staff #2 & #3 did not have a current First Aid/CPR Training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2