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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610333
Report Date: 11/01/2024
Date Signed: 11/01/2024 03:50:14 PM

Document Has Been Signed on 11/01/2024 03:50 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 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: 5DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Jennifer Bihasa TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 11/01/2024 and was greeted by the caregiver. The Administrator Nicole De Las Alas was called. LPA stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are five residents. The facility is licensed for five (5) non-ambulatory residents and one bedridden resident.

LPA Spaeth and the caregiver toured the facility at 10:00 am until 10:30 am.

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room area contained a dining room table and chairs.

Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were locked. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located near the kitchen and is operable.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet

Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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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 IV
FACILITY NUMBER: 197610333
VISIT DATE: 11/01/2024
NARRATIVE
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Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. At 10:20 am, LPA observed there are two residents in the Bedroom 5. LPA also observed an additional empty bed was located in the room and was blocking part of the doorway leading in and out of the room. At 10:35 am, LPA spoke to the Licensee, Nicole De Las Alas and stated the bed needs to be removed as soon as possible. During LPA's visit, the additional bed was removed at 11:00 am

Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats.

Water Temperature: The water temperature was tested at 10:25 am and was 130 Degrees F. The water heater temperature was lowered. LPA tested the water temperature again at 11:09 am and the temperature was 115.0 degrees F.

Hallway Cabinet- LPA observed the clean linens were located in a cabinet.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard in a shaded area

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 11:30 am and were operable.

LPA Spaeth reviewed the resident files at 10:45 am until 11:07 am and reviewed the staff staff files at 11:07 am until 11:20 am. LPA reviewed the medications at 11:30 am until 11:55 am.



Based upon LPA's observations, the following deficiencies were issued.

Exit interview conducted, appeal rights were discussed, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/01/2024 03:50 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/01/2024 at 01:58 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 IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Two out of the five residents' files did not contain the physicians's report (LIC 602) which poses an immediate health, safety risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
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2
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4
The Licensee will send the LIC 602 for the two residents via email to LPA Spaeth
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/01/2024 03:50 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/01/2024 at 01:58 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 IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Two out of the five residents' files did not contain an appraisal, needs assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
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The Licensee will send the appraisal needs assessments for the two residents via email to LPA Spaeth.
Type B
Section Cited
CCR
87307(d)(2)
87307 Personal Accommodations & Services (d) the following space & safety provisions shall apply…(2) The premises shall be maintained in a state…and shall provide a safe and healthful environment . This was evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. Within bedroom 5, an empty additional bed was in the room and was blocking the exit out the door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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LPA observed the additional empty bed was removed during LPA's visit.
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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/01/2024 03:50 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/01/2024 at 02:04 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 IV
FACILITY NUMBER: 197610333

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(3)(2)
87303 Maintenance & Operation e water supplies & plumbing fixtures shall be maintained…(2) Faucets used by residents for personal care….Hot water temperature controls shall be maintained….to a temperature of not less than 105 degrees F & not more than 120 degrees F…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited. The water temperature was 131.00 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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During the tour, the hot water temperature to the hot water tank was lowered. LPA Spaeth tested the temperature again at 11:00 am and the temperature was 110 degrees f.
Type A
Section Cited
CCR
87202(a)(2)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. A bedridden resident is in a non-ambulatory room, The resident is in the wrong room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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The Licensee will move to the resident to Room 5, which is designated as a bedridden room.
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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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