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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850326
Report Date: 09/16/2024
Date Signed: 09/17/2024 08:18:25 AM

Document Has Been Signed on 09/17/2024 08:18 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MALI'S PLACE IIFACILITY NUMBER:
565850326
ADMINISTRATOR/
DIRECTOR:		JACKSON, SARAFACILITY TYPE:
740
ADDRESS:52 CAMINO CASTENADATELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Sara JacksonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived unannounced to conduct a one year required annual at 10:00 A.M. Upon arrival, the LPA was greeted at the door by caregiver, Marietta Acosta. The Administrator, Sara Jackson arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

At 10:35 A.M., the LPA along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following observed:

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 11:00 A.M. hot water measured 115.4 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 08/02/2024. The facility has both smoke detectors and separate smoke detector/carbon monoxide detector, which were tested at 11:30 A.M. and were functional at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms. Room between kitchen and garage is designated as a staff room.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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 09/17/2024 08:18 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/16/2024 at 02:31 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: MALI'S PLACE II
FACILITY NUMBER: 565850326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a stopper keeping fire door from closing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Administrator instructed staff to keep door closed at all times and will provide each resident on the other side with an alert pendant, allowing staff to hear their requests for help from their rooms.
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having all four (4) staff emmbers associated to Mali's 2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee associeated all four (4) staff to Mali's 2 during annual 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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/17/2024 08:18 AM - It Cannot Be Edited


Created By: Valeria Conway On 09/16/2024 at 02:31 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: MALI'S PLACE II
FACILITY NUMBER: 565850326

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having 2 out of 3 resident's outdated Needs and Service Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Administrator will provide up to date Needs and Service plan for R1 and R2
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


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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: MALI'S PLACE II
FACILITY NUMBER: 565850326
VISIT DATE: 09/16/2024
NARRATIVE
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Continued from LIC 809

RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the physical plant tour, water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit.

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. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. The LPA observed the required postings in a hallway next to room #3. LPA asked Administrator to move posters into the common area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during the visit fire door was kept open with a stopper. At 11:58 A.M. Administrator contacted Richard Martinez, fire inspector. During their conversation, Mr. Martinez stated that during his inspection visit, instructed staff not to use stopper to keep door open.

Continued on LIC 809-C

OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for resident use. There was a shaded area with sufficient room for activities. Exit gates were observed to be self-closing and self-latching. Passageways were observed to be clear and free of hazards. No bodies of water noted at the time of visit.



GARAGE: A locked garage is accessible from the exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies. The exterior passageways were clean and clear of any obstructions. Washer, dryer, cleaning supplies and chemicals are stored and inaccessible to residents.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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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: MALI'S PLACE II
FACILITY NUMBER: 565850326
VISIT DATE: 09/16/2024
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Continued from LIC 809C

RECORDS: Records review began at 12:30 P.M. LPA reviewed three (3) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. During record review, LPA observed Resident #1 had an incomplete Needs and Service plan and Resident #2 (R2) had an outdated Needs and Service plan dated on 05/2023. All other records were in order. Also, LPA reviewed five (5) personnel records including licensee. Per the Guardian website, all four staff were not associated to this facility. During records review, LPA observed that staff #1 (S1), staff #2 (S2), staff #3 (S3) and staff #4 (S4) were all separated on 10/20/2023. Licensee, Joseph Jose, associated all four (4) staff today before annual visit concluded. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Last emergency drill (Fire) was conducted on 08/06/2024.

MEDICATIONS: Medications review began at 2:00 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. Medications are properly documented on the Centrally Store Medication log provided by the pharmacy at the time of the visit. A first aid kit was observed in the hallway cabinet.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)

Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
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