565800421-1-27-2022-29-AS-SWAR-CB3R34-20220127113919

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800421
Report Date: 01/27/2022
Date Signed: 01/27/2022 11:40:09 AM

Document Has Been Signed on 01/27/2022 11:40 AM - 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:	MILLENIUM CARE		FACILITY NUMBER:	565800421
ADMINISTRATOR:	MAYA X. DAVIDSZ		FACILITY TYPE:	740
ADDRESS:	1555 HILGARD AVENUE		TELEPHONE:	(805) 526-4440
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 6	DATE:	01/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Iris Vankralingen, Administrator		TIME COMPLETED:	11:40 AM

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

Licensing Program Analysts (LPAs) Salia Walker and Elsie Campos arrived at the facility unannounced to conduct a required Annual visit at 9:25 a.m. This annual had a specific emphasis on infection control practices and procedures. Upon arrival the LPAs met with two (2) staff. The LPAs met with Administrator Iris Vankraligen at 9:44 a.m., and explained the reason for the visit.

The LPAs toured the physical plant areas inside and outside, with Iris Vankralingen at 9:45 a.m., to ensure there are no health and safety hazards.
BEDROOMS: The LPAs observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPAs observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 9:54 a.m. and 9:55 a.m., hot water temperatures measured between 105.5 and 105.7 degrees Fahrenheit in the common and private bathroom(s).
KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:47 a.m., the LPAs observed accessible sharps/culinary knives in the facility’s kitchen drawer next to the oven. The Administrator confirmed the facility does currently have residents with Dementia. The LPAs advised the administrator that all sharp items including culinary knives must be locked at secured at all times. Repairs were made to the facility kitchen drawer containing the culinary knives during visit. Kitchen cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 108.7 degrees Fahrenheit at 9:47 a.m.

Continued on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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

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: MILLENIUM CARE	FACILITY NUMBER: 565800421
	VISIT DATE: 01/27/2022

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
26
27
28
29
30
31
32

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed required postings on the wall near the front entry way. Two (2) fire extinguishers were observed to be fully charged with a service date of 01/2021. At 9:58 a.m., the LPAs observed the facility’s laundry area did not have a lock/latch to properly secure, and there were accessible laundry cleaning supplies and chemicals. Facility staff placed a lock securing the accessible items during the visit.
BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility garage is attached to the facility, and is currently being utilized as storage.
INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs 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. The facility does not have a confirmed case of COVID-19 at this time and the LPAs reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were discussed and provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/27/2022 11:40 AM - It Cannot Be Edited

Created By: Salia Walker On 01/27/2022 at 11:25 AM

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: MILLENIUM CARE	FACILITY NUMBER: 565800421
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

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). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above as culinary knives were accessible to residents with dementia in the facility kitchen cabinet next to the stove, which poses an immediate health, safety risk to persons in care.
	POC Due Date: 01/27/2022
	Plan of Correction
1 2 3 4	POC met during visit.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above, as the licensee did not ensure that chemicals and cleaning supplies were inaccessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/27/2022
	Plan of Correction
1 2 3 4	POC met during 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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Salia Walker

LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3