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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222545
Report Date: 07/16/2024
Date Signed: 07/16/2024 06:28:22 PM


Document Has Been Signed on 07/16/2024 06:28 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
WOODLAND HILLS N.ASC, 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: 4DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Eugenia AbrigoTIME COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Trevor Byrne and Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:05AM. LPAs met with Licensee/Administrator Eugenia Abrigo. Entrance interview conducted.

Beginning at 10:15AM, the LPAs, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and recently serviced on 05/16/2024. Smoke and carbon monoxide detectors were tested at 11:11AM and all were functional at the time of the visit.

KITCHEN: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of 7 (seven) days non-perishable and 2 (two) days perishable food. Knives were observed to be locked in a cabinet above the stove. The stove did not have knobs and was free of safety and hazard concerns. Cleaning supplies are located in a locked under-sink cabinet. At 10:18AM, LPAs began checking the food supply in the kitchen pantry. A total of 11 (eleven) cans were found to be expired and/or dented, making them unsafe for consumption. The LPAs observed the temperature of the freezer to be set at 8 degrees Fahrenheit, but food items in the freezer were thawed and room temperature. Staff 1 (S1) disposed of all expired/dented cans and the full contents of the freezer. Facility does not have an adequate emergency water supply.

BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At 10:54AM, staff room was observed to be unlocked and contained unsecured cleaning supplies and medications, making them accessible to residents.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as only 1 staff file contained an active 1st aid/CPR license which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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2
3
4
Licensee will submit proof of appropriate course enrollment to CCL no later than POC due date
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as only 1 staff file contained an active 1st aid/CPR license which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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2
3
4
Licensee will submit proof of appropriate course enrollment to CCL no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as a staff member who is not med trained assists with medication administration which poses an immediate health risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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LIcensee will ensure non-med trained staff do not handle medication. Licensee will submit a statement of understanding that they have reviewed HSC 1569.69(a). Licensee may submit proof that staff is enrolled in appropriate training for medication handling.
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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4
Based on observation, the licensee did not comply with the section cited above as they retained damaged and expired canned goods which poses an immediate health risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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4
Licensee disposed of all expired and damaged foods at the time of the visit. POC Cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 4 (four) out of 4 (four) resident files which poses an immediate health risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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4
Licensee will contact resident's physicians to obtain a PRN authorization form. Licensee will submit proof of contact or proof of PRN authorization to CCL no later than POC due date.
Type A
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 the facility does not maintain an adequate supply of emergency water which poses an immediate health or safety risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Licensee will submit proof to CCL that they have obtained an adequate supply of emergency water no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above as they were unable to provide a copy of the facility's liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee will submit a copy of their liability insurance to CCL no later than POC due date.
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as outdoor rails connected to emergency evacuation ramps are not properly secure which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Licensee will contact an appropriate maintinence professional and will submit proof of a repair quote to CCL no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as cleaning solutions were observed unsecured in the undersink cabinet of a private resident restroom which posed a potential health risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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2
3
4
Licensee removed cleaning supplies at the time of visit. POC cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 (four) out of 4 (four) staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will submit proof of enrollment in all required training classes for all staff members to CCL no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 (two) out of 4 (four) resident files who were missing their pre-placement appraisal which poses a potential health risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will contact resident's physicians to obtain an up to date medical assessment and submit proof of scheduled physician's appointment or an updated medical assessment to CCL no later than POC due date.
Type B
Section Cited
CCR
87458(b)
Medical Assessment
(b) The medical assessment shall include, but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in 2 (two) out of 4 (four) resident files which did not contain a health assessment which poses a potential health risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will contact resident's physicians to obtain an up to date medical assessment and submit proof of scheduled physician's appointment or an updated medical assessment to CCL no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility had no records of disaster drills taking place which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will submit proof of a completed quarterly disaster drill to CCL no later than POC due date.
Type B
Section Cited
CCR
87212(b)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as they did not have an adequate emergency disaster plan which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will submit an updated emergency disaster plan containing all pertinent information to CCL no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: WOODLAND HILLS MANOR

FACILITY NUMBER: 191222545

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 (four) out of 4 (four) resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will provide proof to CCL that they have contacted resident's physicians to provide orders for bed rails no later than POC due date.
Type B
Section Cited
CCR
87469(a)
Advance Directives and Requests Regarding Resuscitative Measures
(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 (four) out of 4 (four) resident files which poses a potential personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
1
2
3
4
Licensee will print out the required consent forms and have the resident or resident's designee sign the documents. Licensee will submit proof to CCL that the appropriate documents have been signed and added to resident files no later than 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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WOODLAND HILLS MANOR
FACILITY NUMBER: 191222545
VISIT DATE: 07/16/2024
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BATHROOMS: There are 4 (four) bathrooms for resident use. 2 (two) are designated for shared resident use and the other 2 (two) are private resident restrooms. Restrooms were observed to contain nonskid mats. Grab bars were observed in the bathrooms. At 10:30AM, LPAs observed bathroom #1 to contain an unsecured cleaning product under the sink, however resident #1 (R1) was in the hospital at the time of the visit. At 11:14AM, the LPAs observed the shower grab bar in bathroom #4 connected to bedroom #4 to be loose. The water temperature was measured in all resident bathrooms and measured between 104.7 and 109.8 degrees Fahrenheit, which is outside the required range of 105 and 120 degrees Fahrenheit.

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. The living room has a properly screened fireplace. Exit doors contain alarms and all but the kitchen sliding door were functional at the time of the visit.

GARAGE Washer and dryer were observed to be in the locked garage. Garage was designated as an additional living quarters for staff use but was not utilized at the time of the visit.

OUTDOOR SPACE: The backyard and front yard have sitting areas with patio furniture including tables and chairs for resident use. The passageway on the east side of the facility was obstructed with a hospice bed. S1 notified LPAs that it was left out to be picked up by the hospice provider. There were no bodies of water on the premises. An outdoor shed was observed to be locked. The passageways on both sides of the house contain railings but were observed to be loose at the time of the visit.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs attempted to review the emergency disaster plan. The facility’s policies and procedures as it pertains to emergency disasters are not updated annually and disaster drills are not conducted quarterly as required.

RECORD REVIEW: LPAs began record review at 11:23 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 4 (four) staff files observed were missing documents. 4 (four) of 4 (four) resident files were observed to be missing required documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. At 12:26PM, LPAs observed writing on medication labels by facility staff. Facility did not have PRN authorization letters and guidelines for all PRN medications observed. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
Page: 45 of 46
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WOODLAND HILLS MANOR
FACILITY NUMBER: 191222545
VISIT DATE: 07/16/2024
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INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents.

During today's visit, LPAs were not able to obtain a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-Ds). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
Page: 46 of 46