565801311-12-1-2023-29-AS-ECOZ-CY4VVN-20231201154636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801311
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:47:06 PM

Document Has Been Signed on 12/01/2023 03:47 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HAAVE HOUSE		FACILITY NUMBER:	565801311
ADMINISTRATOR:	BONNIE M. HAAVE		FACILITY TYPE:	740
ADDRESS:	315 RIVERSIDE ROAD		TELEPHONE:	(805) 649-0704
CITY:	OAK VIEW	STATE: CA	ZIP CODE:	93022
CAPACITY: 6		CENSUS: 6	DATE:	12/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Bonnie Haave		TIME COMPLETED:	03:50 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	At 09:05 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Licensee Bonnie Haave and informed them of the reason for the visit. Record Review: At 09:15 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of six (6) resident files. The LPA reviewed five (5) out of five (5) staff files. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/10/2023). The LPA obtained a Client Roster and Staff Roster. All documents reviewed appeared complete and current. Interviews: At 12:30 p.m. the LPA conducted two (2) staff and two (2) resident Interviews. No immediate concerns were voiced. Medications: At 1:00 p.m. a medications review was initiated. Medications are centrally stored and locked in a hallway closet; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record, however, start dates for several medications of all residents were not documented. A conversation was held between the LPA and Licensee Bonnie of the importance of best practice in writing a start date for all medications. Licensee Bonnie stated that moving forward, the start date for all medications will be documented. At 02:40 p.m. the LPA conducted a tour of the physical plant with Licensee Bonnie Haave to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms, one (1) staff room, and two (2) restrooms. The LPA observed one (1) fire extinguishers which was fully charged and last serviced 01/02/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the kitchen. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Report will continue on LIC809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAAVE HOUSE	FACILITY NUMBER: 565801311
	VISIT DATE: 12/01/2023

NARRATIVE

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Kitchen: During the facility tour at 02:40 p.m. the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharps are stored in a locked drawer. At 2:42 p.m. the LPA observed a steak knife unattended in the kitchen accessible to residents in care. Upon observation, staff locked the knife away.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 2:44 p.m. the LPA observed staff room unlocked with medication accessible to residents in care. Upon observation, staff locked the staff room.
Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 2:53 p.m. water temperature in resident’s restroom was measured at 106.4 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.
Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 74 degrees. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies and disinfectants are kept in a locked closet in the hallway between the kitchen and bedrooms along with the washer and dryer.
The garage: The LPA observed the garage, where the emergency food and water is stored. The garage is locked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The home’s policies and procedures pertaining to infection control were adequate.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Licensee Bonnie Haave.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/01/2023 03:47 PM - It Cannot Be Edited

Created By: Esther Cortez On 12/01/2023 at 03:29 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: HAAVE HOUSE	FACILITY NUMBER: 565801311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

(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 observation, the licensee did not comply with the section cited above as the LPA observed a steak knife unattended in the kitchen and an unlocked staff room with medication accessible to residents in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Steak knife and staff room were locked upon observation during the time of visit. Licensee Bonnie agreed to provide training to all staff on section 87705(f) and provide proof to CCL by POC due date 12/08/2023.

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:

Kasandra Lopez

LICENSING EVALUATOR NAME:

Esther Cortez

LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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