565802469-6-5-2023-29-AS-ECAS-CSHVR5-20230605163921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802469
Report Date: 06/05/2023
Date Signed: 06/05/2023 04:39:40 PM

Document Has Been Signed on 06/05/2023 04:39 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:	CARMEL HOME		FACILITY NUMBER:	565802469
ADMINISTRATOR:	FROILAN MONTES		FACILITY TYPE:	740
ADDRESS:	1090 CARMEL DR		TELEPHONE:	(805) 955-0435
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	06/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Alma Flores		TIME COMPLETED:	04:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:30 a.m. The LPA met with Administrator Alma Flores and explained the reason for the visit.

The LPA, and the Administrator toured the physical plant areas at 11:00 a.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 11:05 a.m. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated client rooms. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: The three client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the large hallway bathroom at 115.7 degrees Fahrenheit at 11:26 a.m.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 2:03 p.m. and operational at the time of the visit. The three (3) fire extinguishers were fully charged and were last serviced Feb 6, 2023. The LPA observed required postings throughout the common space. The Administrator was advised to post the Emergency Disaster Plan on the bulletin board.

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

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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Document Has Been Signed on 06/05/2023 04:39 PM - It Cannot Be Edited

Created By: Elsie Campos On 06/05/2023 at 03:47 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: CARMEL HOME	FACILITY NUMBER: 565802469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(13)(B)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 3 out of 5 records reviewed did not have the required LIC 508 Criminal Record Statement and 5 out 5 did not have the LIC 501 and LIC 9052 in the individual's personnel file which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/09/2023
	Plan of Correction
1 2 3 4	The Licensee agrees to do the following: Audit all staff files and ensure that all files have a completed LIC 508, LIC 501 and LIC 9052. Provide proof to CCL no later than the end of day 6/9/2023.

Section Cited

Criminal Record Clearance


	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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2023 04:39 PM - It Cannot Be Edited

Created By: Elsie Campos On 06/05/2023 at 03:53 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: CARMEL HOME	FACILITY NUMBER: 565802469
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(4)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Staff #5 (S5) was found not to be associated to the facility which poses an immediate health and safetyrisk to persons in care.
	POC Due Date: 06/06/2023
	Plan of Correction
1 2 3 4	The Licensee agreed to do the following: Immediatley associate staff #5 to the facility. Plan of correction met at the time of the visit. Civil penalty assessed.

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Elsie Campos

LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARMEL HOME	FACILITY NUMBER: 565802469
	VISIT DATE: 06/05/2023

NARRATIVE

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted. The garage is attached to the facility, and this is where the washer and dryer are held, including additional refrigerator with perishable food items. Cleaning supplies and disinfectants are kept in locked in the garage.

RECORDS: Residents’ records review began at 12:45 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were incomplete and missing LIC 501 CCL Personnel Record and LIC 9052 Employee Rights for Staff #1, #2, #3, #4 and #5. LIC 508 Criminal Record Clearance was missing for Staff #1, #4 and #5. Additionally record review revealed that Staff #5 was not associated to the facility. Administrator completed association at the time of the visit.

MEDICATIONS: Medications review began at 11:40 a.m.; medications are centrally stored and locked in a cabinet in the breakfast nook of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 LPA discussed the new PIN changes regarding infection control.

The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, Staff schedule.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided. Civil Penalty assessed in the amount of $500.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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