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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 09/05/2024
Date Signed: 09/05/2024 02:13:32 PM

Document Has Been Signed on 09/05/2024 02:13 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:RESIDENCE AT DEAN LLC, THEFACILITY NUMBER:
565850268
ADMINISTRATOR/
DIRECTOR:		LIMBO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:4032 DEAN DRIVETELEPHONE:
(805) 402-0304
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 5CENSUS: 4DATE:
09/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:May DavisTIME VISIT/
INSPECTION COMPLETED:
02:30 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
Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required
annual visit at 10:15 a.m. When the LPA arrived, there was one staff and four residents present. The LPA was greeted by a caregiver staff 1 (S1) and informed them of the reason for the visit. Back-up Administrator Mae Davis arrived shortly after S1 called. The back-up administrator works at the licensee's other facilities.

At 10:18 a.m. LPA conducted a tour of the facility and conducted interviews during the physical plant tour.
The facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms.
There is one (1) additional bedroom for staff use. The fire extinguisher was last serviced on 9/15/2023 and appeared fully charged. The smoke and carbon monoxide detectors were tested and functioned properly. LPA observed required postings near the entry.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA
observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked drawer to the right of the stove and cleaning supplies are stored in a locked cabinet under the sink. LPA observed the cabinet storing cleaning supplies was unlocked and unsupervised.
Bedrooms: The resident bedrooms were properly furnished with adequate lighting, and clean bedding.
Bathrooms: The LPA observed one private resident bathroom, one bathroom used by staff, and one bathroom used by the three other residents. All bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats. Residents have sufficient amounts of supplies for
personal hygiene. The hot water was measured at 112.5*F in the private bathroom and 114.9*F in the other resident bathroom which is within the required limit of 105-120 degrees Fahrenheit. LPA observed in the staff bathroom there were cleaning supplies such as bleach stored in an unlocked cabinet under the sink.

(continued on LIC809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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 4
Document Has Been Signed on 09/05/2024 02:13 PM - It Cannot Be Edited


Created By: Teresa Camara On 09/05/2024 at 01:15 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: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above in three out of three areas of concern - bathroom, kitchen, laundry cabinets left unlocked with cleaning detergents/chemicals accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
The back-up administrator locked all of the cabinets. Licensee will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Licensee will submit evidence of training to CCL on or before 9/13/2024.
Type A
Section Cited
CCR
87355(e)
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:

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 one out of seven staff; S1 does not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
1
2
3
4
The back-up administrator called another staff in to take over caregiver duties until S1 can get fingerprint cleared and assoicated to the facility.
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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/05/2024 02:13 PM - It Cannot Be Edited


Created By: Teresa Camara On 09/05/2024 at 01:15 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: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
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: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 one out of seven staff who did not have a health screening on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
Licensee will have S1 get a health screening and provide CCL with evidence of the health screening on or before 9/13/2024.
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:Desaree Perera
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268
VISIT DATE: 09/05/2024
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
(continued from LIC809)

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. The facility maintained a
comfortable temperature of approximately 72 degrees.

Garage: The garage is where additional non-perishable emergency food items are held. Cleaning supplies and disinfectants are kept in the garage. The garage is locked and inaccessible to the residents in care.
Laundry Room: The laundry room cabinets were observed to be unlocked with the laundry detergent accessible.
Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

File review: LPA reviewed administrator and staff files which were complete, including training. The administrator was off-site during LPA's visit but sent LPA documents that were requested by text and email during the visit. S1 is a new caregiver at this facility. S1 was not fingerprint cleared or associated to this facility; nor did S1 have a health screening on file. S1 stated they work as a private in-home caregiver and had fingerprint clearance but it did not show up in the CCL system. S1 stated this is their fourth day working at the facility. The back-up administrator called for another staff to relieve S1 until S1 can get cleared and associated to this facility. LPA reviewed all four residents' files which were complete. The LPA reviewed the facility's Infection Control Plan, Disaster Plan and evacuation drills.

Interviews: LPA conducted interviews with two residents and one staff. No immediate concerns were voiced during the visit.

Medication audit: Medications were reviewed. Medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. The Centrally Stored Medication and Destruction Records were completed. Medications appeared to be given as prescribed.

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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4