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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610022
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:04:19 PM

Document Has Been Signed on 09/26/2024 04:04 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:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR/
DIRECTOR:		OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Myline OlivasTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were three (3) staff and four (4) residents present. LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Myline Olivas arrived at 9:57am. Entrance interview conducted.

At 9:58am, the LPA along with the 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:

KITCHEN: The LPA inspected the kitchen/food service area at 10:01am. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:08am, the hot was temperature was checked in the kitchen sink and it measured 107.6 degrees Fahrenheit.

COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately and appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities for resident use were observed by the hallway. LPA observed auditory alarms at the time of the visit. There is a working telephone on premises. LPA observed fireplace adequately covered during the inspection.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 09/26/2024
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Report Continued from LIC 809...

Fire extinguisher was observed fully charged with a date of 8/09/2024. At 10:19am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 08/1/2024.

RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 107.6 degrees Fahrenheit at 10:10am; and the second bathroom measured at 106.8 degrees Fahrenheit at 10:14am.

BEDROOMS: There are four (4) bedrooms for resident use; two (2) bedrooms are designated as single occupancy; and two (2) bedrooms are designated as double occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. Staff bedroom observed on premises.

GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator and freezer with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed in a locked cabinet inaccessible to residents in care. Facility has an adequate amount of emergency food and water. LPA observed a sufficient supply of Personal Protection Equipment (PPE).



BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 09/26/2024
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Report Continued from LIC 809C...

RECORDS: LPA reviewed Resident Records at 10:26am and Personnel Records at 11:22am.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. Although the facility has a designated training binder, the LPA was unable to determine the number of hours completed per regulation for the past 12 months.

MEDICATIONS: Medications review began at approximately 12:45pm. Medications are stored in a locked cabinet adjacent to the kitchen inaccessible to residents in care.

At 1:15pm, Resident #1’s (R1’s) centrally stored medication and destruction record (CSMDR) does not have PRN medication for Lorazepam 1mg tablet qty-30, date filled 08/12/2024, documented and has been started, as there are fifteen (15) tablets that have been administered. At 1:31pm, Resident #2's (R2's) CSMDR did not have medication Flecainide Acet tabs 50mg, date filled 07/26/2024 documented. Additionally, a separate bottle of Flecainide 50mg, date filled 08/28/2024 was documented on the CSMDR with a start date of 09/07/2024 was counted and had 49 pill remaining; however, there was no refusals documented which would indicate there would be 24 pills remaining.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 04:04 PM - It Cannot Be Edited


Created By: Martha Arroyo On 09/26/2024 at 03:04 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: APPLETON HOMES
FACILITY NUMBER: 567610022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
HSC
1569.69(e)(3)(C)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: (C) The times, dates, and hours of training provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above as staff training does not have times, dates, and hours of training provided as Administrator stated they only sign off on all the training on one (1) day, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The Licensee will review Regulation and submit a statement of understanding to CCL on or before POC due date.
Request Denied
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and inetrview, the licensee did not comply with the section cited above as not all medication being received by the facility is being proprely documented on the CSMDR, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The Licensee will create a plan on how the faciltiy will ensure all medication is properly documented on the CSMDR and submit to CCL on or before 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:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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