567610000-12-10-2022-29-AS-MARO-CLYSAH-20221210124220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610000
Report Date: 12/10/2022
Date Signed: 12/10/2022 12:43:27 PM

Document Has Been Signed on 12/10/2022 12:43 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:	12/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Karina Antig		TIME COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 10:30 a.m. The last annual conducted at this facility was on 01/28/2022. Upon arrival, the LPA was scanned and greeted at the door by Staff. The Administrator, Karina Antig arrived shortly after and the reason for the visit was explained. Entrance interview.

During today’s inspection, the LPA toured the common areas, kitchen area, resident bedrooms, 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 LPA observed a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. All knives and sharps are kept locked in a top cabinet inaccessible to residents in care. Medication and resident files were observed locked in a cabinet next to the sharps. RESTROOMS: There are two (2) resident restrooms. 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. Restrooms were measured for hot water; first restroom measured at 145.6 degrees Fahrenheit at 10:53 a.m., and second restroom measured at 147.2 degrees Fahrenheit at 10:55 a.m. The Administrator adjusted the water temperature at the time of visit. Additionally, the Administrator was advised of a civil penalty being assessed today due to this being a repeat violation. ...Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

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: 12/10/2022

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…Report Continued from LIC 809...

GARAGE AND BACKYARD: The garage is locked and inaccessible to residents. There is one (1) additional refrigerator in the garage with additional food. The LPA observed a sufficient supply of emergency water and food in the garage. There is a patio area with furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No bodies of water observed during time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use.

INFECTION CONTROL: 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. 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.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

The facility was cited for this violation on 01/28/2022. Therefore, a civil penalty of $250 is being assessed today due to a repeat violation. (See LIC 421FC).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/10/2022 12:43 PM - It Cannot Be Edited

Created By: Martha Arroyo On 12/10/2022 at 11:41 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: 12/10/2022

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 LPA observation, the licensee did not comply with the section cited above as two (2) out of two (2) resident restroom faucets delivers hot water measured at 147.2 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/10/2022
	Plan of Correction
1 2 3 4	Plan of Correction has been met. The Administrator adjusted the water temperature at the time of visit. A $250 civil penalty is being assessed today due to a repeat violation within 12 months.

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 Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022

LIC809 (FAS) - (06/04)

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