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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610000
Report Date: 05/14/2021
Date Signed: 05/14/2021 04:28:05 PM

Document Has Been Signed on 05/14/2021 04:28 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:ERTEN HOME CAREFACILITY NUMBER:
567610000
ADMINISTRATOR:ROSALES, KARENFACILITY TYPE:
740
ADDRESS:212 ERTEN ST.TELEPHONE:
(818) 219-5998
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 1DATE:
05/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Michael Rosales and Rhodora IlanTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Kelly Dulek and Martha Guzman Chavez visited the facility for complaint #29-AS-20210507143030. During the course of the investigation, LPAs observed deficiencies unrelated to the complaint.

LPAs toured the facility with facility designees Michael Rosales and Rhodora Ilan at 11:20AM. At 11:21AM, LPAs observed 2 small open containers of urine on top of Resident #1 (R1)'s dresser. At 11:23AM, LPAs observed the following cleaning supplies unlocked and stored improperly: bleach in an unlocked staff room, Pine Sol, laundry detergent, and oil soap cleaner stored in the locked medication cabinet, and floor cleaner stored outside in the patio area, accessible to residents in care. At 11:26AM, LPAs observed a vinyl fence on the side yard to be laying down in the neighbor's yard. The facility does have a retaining wall on the slope between the patio and the neighbor's yard and facility designee Rosales explained that the fence is on the neighbor's property, however, there is direct access from the neighbor's yard into the facility backyard and side yard areas.

LPAs also noted that facility designee Michael Rosales does not have fingerprint background clearance for this facility at this time.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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 05/14/2021 04:28 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/14/2021 at 03:45 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: ERTEN HOME CARE
FACILITY NUMBER: 567610000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2021
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions...shall be stored where inaccessible to clients. (b) Medicines which are centrally stored shall be stored...separately from other items specified in (a) above.
This requirement is not met as evidenced by:
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During the visit, all items were secured in a locked location separate from all medications. Training will be provided to all staff on section 87309 and proof of training will be provided to CCL by 5/21/2021.
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Based on observation, a bottle of bleach and floor cleaner were stored unlocked in the facility and on the patio and laundry soap, Pine Sol, and oil soap cleaner were stored in the medication cabinet, which poses an immediate health and safety risk to residents in care.
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2021 04:28 PM - It Cannot Be Edited


Created By: Kelly Dulek On 05/14/2021 at 03:13 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: ERTEN HOME CARE
FACILITY NUMBER: 567610000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2021
Section Cited
HSC
87355(b)(1)(A)

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87355 Criminal Record Clearance (b) In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons:
(1) (A) Adults responsible for administration or direct supervision of staff.
This requirement is not met as evidenced by:
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Facility designee agreed to submit to CCL fingerprint background exemption documents and receive background clearance prior to the facility designee returning to the facility.
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Based on observation and record review, the facility designee is not fingerprint background associated to the facility, which poses an immediate safety risk to residents in care.
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Type A
05/15/2021
Section Cited
CCR87468.1(a)(2)

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87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Facility designee ensured the containers of urine were removed during the visit. Training will be provided to staff on proper disposal of incontinence care items by 5/21/2021. Designee agreed to ensure the fence is fixed or another means of blocking access is utilized by 5/21/2021.
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Based on observation, there were open containers of urine in R1's room and the fence between the facility yard and neighbor's yard was laying down, allowing open access to the facility, which is an immediate health and safety and personal rights risk to residents in care.
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Proof of training and photos of fence repairs to be sent to CCL by 5/21/2021.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021


LIC809 (FAS) - (06/04)
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