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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222545
Report Date: 07/11/2022
Date Signed: 07/11/2022 12:23:09 PM

Document Has Been Signed on 07/11/2022 12:23 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:WOODLAND HILLS MANORFACILITY NUMBER:
191222545
ADMINISTRATOR:ABRIGO, EUGENIAFACILITY TYPE:
740
ADDRESS:22642 VICTORY BLVD.TELEPHONE:
(818) 594-5994
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Eugenia AbrigoTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at approximately 9:10 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Eugenia Abrigo and explained the reason for the visit.

At 9:27 a.m. the LPA toured the physical plant areas inside and outside with Administrator Eugenia Abrigo to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:53 a.m. the LPA observed two expired packages of sandwich meat. An unsealed bacon package was also observed. The administrator was reminded to ensure that all food items are properly sealed and audited for expiration. The administrator discarded expired items at the time of the visit.

BEDROOMS: The LPA observed six resident bedrooms and one staff bedroom. Bedrooms were private with Bedroom #1 and Bedroom #4 containing a private bathroom. All resident bedrooms had an exit to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: The facility has 4 bathrooms. Bathrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate hand-washing signs in the restrooms. At 9:29 a.m. the LPA observed accessible cleaning supplies under the bathroom sink in bedroom #1. Water temperature measured between 127.0 degrees Fahrenheit and 130.4 degrees Fahrenheit between 9:32 a.m. and 9:41 a.m. The administrator was reminded about water temperature regulations and adjusted the temperature at the time of the visit.

Continued on LIC-809-C.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2022
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: WOODLAND HILLS MANOR
FACILITY NUMBER: 191222545
VISIT DATE: 07/11/2022
NARRATIVE
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COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Passageways were clean and clear of obstructions. No accessible bodies of water were observed on the property at the time of the visit. The facility has a designated visitation area located outside in a shaded area with appropriate furniture and seating for residents. The LPA observed all the required postings in the dining room and the hallway that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Medications are kept locked inaccessible in the kitchen area filing cabinet. A medication lock box was observed in the kitchen refrigerator inaccessible to residents. Hand sanitizer was available for staff and resident use. Fire Extinguisher was last bought 5/22/2022. Administrator tested fire alarm system at 10:03 a.m., the LPA observed that it was working at the time of the visit. At 9:33 a.m. the LPA observed disinfectants accessible to residents in the common hallway and unlocked supply cabinet located in the hallway. The administrator secured all items at the time of the visit.

GARAGE: There is a detached garage and a detached laundry room. The LPA observed an outdoor storage closet containing additional cleaning supplies, additional Personal Protective Equipment (PPE) and incontinence supplies. The garage was locked making it inaccessible to residents. The administrator indicated that the garage is used as a sleeping quarters for her niece who is associated to the facility. A fire extinguisher was observed at the time of the visit.

INFECTION CONTROL: 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). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator continues to conduct testing, regardless of vaccination status. The facility’s policies and procedures as it pertains to infection control are adequate. At the time of the LPA’s arrival, staff was observed not wearing face masks. The administrator was reminded that face mask guidelines are still in place.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report, LIC 809-D, and Appeal Rights were discussed and provided to Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/11/2022 12:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 07/11/2022 at 11:23 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: WOODLAND HILLS MANOR
FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

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
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Based on observation, the licensee did not comply with the section cited above, as water temperatures registered above 120 degrees Fahrenheit, which poses an immediate health and safetyrisk to persons in care.
POC Due Date: 07/18/2022
Plan of Correction
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The adminsitrator agreed to do the following:
1. The Administrator will adjust the water temperature and advise the LPA. Correction made at the time of the visit.
2. Thereafter, facility will send a five-day temperature log to demonstrate that the temperature is regulated within range. Temperature log will be sent to the LPA no later than 7/18/2022.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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, as expired perishable and non-perishable food was observed in the cabinet and refridgerator, which poses a potential health and safety risk to persons in care..
POC Due Date: 07/15/2022
Plan of Correction
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The Administrator has agreed to do the following:
1. Audit all food; identify food of poor quality and dispose of properly. Inform CCL when this has taken place, yet no later than 7/15/2022. Expired food disposed of at the time of the visit.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/11/2022 12:23 PM - It Cannot Be Edited


Created By: Elsie Campos On 07/11/2022 at 11:23 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: WOODLAND HILLS MANOR
FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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, as cleaning supplies were accessible, which poses an immediate health and safety risk to residents in care.
POC Due Date: 07/12/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Secure the items. Inform the Department when this takes place, but no later than 7/12/22. Items secured at the time of the visit. POC met.
Type A
Section Cited
CCR
81072

81072 Personal Rights(a)(2) (a) Each client shall have personal rights which include ... the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights risk to residents in care.
POC Due Date: 07/15/2022
Plan of Correction
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The Licensee agrees to do the following:
1. Have an in-service training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 7/15/2022
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022


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