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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850332
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:48:14 PM

Document Has Been Signed on 06/18/2024 05:48 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:INFINITY CARE HOMEFACILITY NUMBER:
565850332
ADMINISTRATOR/
DIRECTOR:		MANACAP, JOCELYNFACILITY TYPE:
740
ADDRESS:944 BELMONT AVENUETELEPHONE:
(805) 419-6012
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jocelyn ManacapTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual visit to this facility at 10:00 a.m., LPA met with backup Administrator Harold De Guzman. Administrator was contacted via telephone and arrived at 11:09 a.m. Entrance interview conducted.

Beginning at 11:12 a.m., the LPA, along with Administrator 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 was observed:

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three (3) total bedrooms, all of which are designated for shared resident use, at the time of the visit only Room #1 is being shared. During the physical plant tour, LPA observed trash cans not to have appropriate waste receptacle with a tight-fitting cover. LPA explained to Administrator the importance of such lids to prevent cross contamination.

RESTROOMS: The LPA observed two (2) restrooms in the facility; one (1) is a shared restroom, and one (1) is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 11:38 a.m. and 11:45 a.m., hot water was measured. All bathrooms were within the required limit of 105-120 degrees Fahrenheit.

Continued on IC 809C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 7
Document Has Been Signed on 06/18/2024 05:48 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/18/2024 at 05:01 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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. LPA observed medication and food inside pantry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator and staff will log unuse medication and propertly discard it.Proof of destruction log will be provided.
Type A
Section Cited
CCR
87415(a)(5)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: (5) In facilities required to have a signal system, specified in Section 87303, Maintenance and Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, the licensee did not comply with the section cited above by having staff sleeping on the couch when tired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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Administrator agrees to write a statement of understanding base on Night Supervision.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document is an Amendment of Original Document on 06/21/2024 04:25 PM


Created By: Valeria Conway On 06/18/2024 at 05:01 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.17(b)(1)(C)
Licensing
(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58.

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 S2 fingerprinted but not associated to Infinity Care Home which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Administrator will associate S2 immidiately and send proof to LPA by POC due date.

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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/18/2024 05:48 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/18/2024 at 05:01 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 conducting readings of TB test to S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2024
Plan of Correction
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Administrator agrees to get TB test from a third party and provide negative TB TEST and send proof to LPA by POC due date

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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/18/2024
NARRATIVE
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Continued from LIC 809

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room was observed to be in good condition. The LPA observed the required postings in the common area. Hardwired combination smoke and carbon monoxide detectors were tested by staff at 10:26 a.m. and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 05/22/2024. The facility maintained a comfortable temperature of 75 degrees. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete. Emergency disaster drills are being conducted quarterly.

KITCHEN: During the inspection, LPA observed inside refrigerator to be stained and the kitchen floor to have crumbs and not clean. LPA explained the importance of mopping regularly and having the facility clean, safe, sanitary and in good repair at all times. Also, at 11:15 a.m., LPA observed Allergy relief medication and an unknown bottle of medication without a label along with oatmeal, cookies, tea bags, coffee and baby food in an unlocked kitchen cabinet. Knives and other sharps were observed locked in a kitchen drawer. Cleaning supplies were observed in a locked under-sink cabinet. At 11:27 a.m., hot water measured at 122.9 degrees Fahrenheit. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

OUTDOOR SPACE: The side yard has a covered outdoor area equipped with furniture for resident to enjoy. There were no bodies of water noted.



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

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/18/2024
NARRATIVE
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Continued from LIC 809C

RECORD REVIEW: Began at 12:01 p.m., staff and resident records were reviewed for documents including, but not limited to, health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) out of four (4) resident records reviewed were complete and contained all required documents. Resident # 1 (R1) records were missing ID form, Needs and service plan, consent form and Preplacement Appraisal form. At 2:00 p.m., five (5) staff files including the administrator were reviewed; Staff #1 (S1) and Staff #2 (S2) record’s had TB test results read by the licensee, Jocelyn Manacap. LPA read regulation 87411(f) from Title 22, Division 6, Chapter 8 Article 7 under Personnel Requirements-General where specifies that a physician shall perform such tests. Furthermore, during the course of the visit and reviewing records with administrator, LPA observed that Staff #2 (S2) is fingerprint cleared but not associated to the facility. Interview with Administrator and documents reviewed reflected S2 has been working in the facility as a backup caregiver since 10/10/2023.

GARAGE: The garage was observed locked. LPA observed extra non-perishable food, and a refrigerator with extra food. Furthermore, laundry area, as well as emergency food supply and water, and storage space was observed in the garage. All cleaning compounds were stored in areas separately from food supplies. Additionally, at 11:14 am, LPA observed several garage storage cabinets with clothes and a chest of drawers full of clothes along with a queen bed with bedding sheets and a sofa bed with sheets and pillows in the garage. Administrator stated that this home used to be where they reside, and they are looking to move to a bigger apartment, until then the staff is using the garage as storage. Administrator stated that S2 works every Friday and Saturday from 7 a.m. to 7 p.m. and brings son along. During today visit staff and administrator stated that when tired they will use common areas to sleep. LPA reminded that during work hours staff primary focus should be the residents. LPA also informed administrator that given that there are no staff rooms, the facility is required to have 24/7 care and that staff cannot use common areas to sleep. LPA requested that the administrator clear all hazards from the garage and submit proof to licensing. Continued on LIC 809C

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

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/18/2024
NARRATIVE
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Continued from LIC 809C

MEDICATION REVIEW: All medications are kept in a hallway closet. This closet is locked at all time and medication are inaccessible to residents. LPA observed a complete 1st aid kit including its manual inside that closet. Audit began at 3:21 p.m. Medications for all residents were observed to be in compliance with Title 22. Physician's Reports indicate Resident #2 (R2) is able to store and administer their own medications. As thus, the facility centrally stores medications for daily administration.

INTERVIEWS: Throughout today's visit, LPA interviewed two (2) staff and one (1) resident. No immediate health or safety concerns noted.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview conducted. A copy of the report was provided.

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

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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