567610000-1-28-2022-29-AS-MGCZ-CB4SEC-20220128124831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610000
Report Date: 01/28/2022
Date Signed: 01/28/2022 12:49:44 PM

Document Has Been Signed on 01/28/2022 12:49 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 CARE		FACILITY NUMBER:	567610000
ADMINISTRATOR:	ROSALES, KAREN		FACILITY TYPE:	740
ADDRESS:	212 ERTEN ST.		TELEPHONE:	(818) 219-5998
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 5	DATE:	01/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Karina Antig		TIME COMPLETED:	12:50 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an unannounced visit to Erten Home Care to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 10:30 a.m. This will be the first Annual from their Pre-Licensing visit on 12/16/2020. The LPA was greeted and screened at the door by caregiver, Princess Alcantara and met with Administrator Karina Antig shortly after when she arrived at 10:45 a.m., and the reason for the visit was explained. Entrance interview.

At 10:46 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated cabinet in the kitchen where knives and sharps are locked and inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, the first bathroom measured at 136.8 degrees Fahrenheit at 10:49 a.m., the second bathroom measured at 133 degrees Fahrenheit at 10:53 a.m., and the third bathroom measure at 114.8 degrees Fahrenheit at 11:06 a.m. Licensee corrected water temperature during visit

…Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

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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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: ERTEN HOME CARE	FACILITY NUMBER: 567610000
	VISIT DATE: 01/28/2022

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…Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals are stored and inaccessible to residents. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed three (3) residents in the living room watching television. Medications are in a locked cabinet inside the staff room.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/28/2022 12:49 PM - It Cannot Be Edited

Created By: Martha Guzman-Chavez On 01/28/2022 at 11:47 AM

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: 01/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above as two (2) out of three (3) facility restroom faucets delivers hot water measured at 136.8 and 133 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/04/2022
	Plan of Correction
1 2 3 4	The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

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:

Martha Guzman-Chavez

LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2022

LIC809 (FAS) - (06/04)

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