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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703748
Report Date: 02/18/2022
Date Signed: 02/18/2022 04:04:34 PM

Document Has Been Signed on 02/18/2022 04:04 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:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Susan MarshTIME COMPLETED:
04:10 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 02/18/22 at 12:50 p.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA toured facility with staff and met with Administrator Susan Marsh. LPA explained the purpose of the visit.

At 1:02 p.m., LPA observed a fire extinguisher in the kitchen with a service tagged punched for November 16, 2018. Facility contacted service company during LPA's visit to have it serviced.
At 1:03 p.m., LPA observed an open clear plastic container on the top of the refrigerator in the kitchen. LPA requested staff to place contents of container onto kitchen counter. LPA counted 28 knives ranging from chef's knife to pairing knives. Some knives had blade as long as 6 inches. This was a repeat deficiency cited on 2/8/2019. LPA asked staff to lock knives away. Staff locked container in the garage. LPA asked Administrator if there were any residents diagnosed with dementia. Administrator replied, "No." LPA reviewed resident's physician's report and noted there was one resident diagnosed with dementia on Physician's Report. LPA asked why knives were there. Administrator stated that it was on top of the refrigerator and out of residence reach.
At 2:00 p.m., LPA discussed items in the Infection Control Module and noted that staff have not been fit tested with N95. LPA also noted that facility does not post or have California Department of Social Services (CDSS) Provider Information Notices (PINs) posted nor available. Facility did not have signs promoting social distancing, cough/sneeze etiquette, or hand washing signs. Hand washing signs were posted prior to LPA's departure. Infection Control module was addressed with administrator to satisfaction.
At 3:00 p.m., LPA informed administrator that PUB 475 needed to be in a size 20"x26". Poster observed in the kitchen was 8.5"x11".

LPA issued citations on 809D, conducted exit interview, and emailed appeal rights, report to the administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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 3
Document Has Been Signed on 02/18/2022 04:04 PM - It Cannot Be Edited


Created By: Toan Luong On 02/18/2022 at 03:04 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, LPA observed service tag of November 16, 2018 on the fire extinguisher. The licensee did not comply with the section cited above in 1 count which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2022
Plan of Correction
1
2
3
4
Facility contacted service company same day and had it serviced in the presence of LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Kelly Burley
LICENSING EVALUATOR NAME:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/18/2022 04:04 PM - It Cannot Be Edited


Created By: Toan Luong On 02/18/2022 at 03:04 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Based on observation and interview, LPA observed an open container with knives on top of the refridgerator. The licensee did not comply with the section cited above in 28 counts which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2022
Plan of Correction
1
2
3
4
Staff locked knives in the garage. Administrator states that cooking is performed by adjacent facility ran by administrator. Administrator stated that knives will remain locked.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Kelly Burley
LICENSING EVALUATOR NAME:Toan Luong
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3