191222545-6-14-2023-29-AS-AASO-CST22T-20230614170115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222545
Report Date: 06/14/2023
Date Signed: 06/14/2023 05:03:51 PM

Document Has Been Signed on 06/14/2023 05:03 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 MANOR		FACILITY NUMBER:	191222545
ADMINISTRATOR:	ABRIGO, EUGENIA		FACILITY TYPE:	740
ADDRESS:	22642 VICTORY BLVD.		TELEPHONE:	(818) 594-5994
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Eugenia Abrigo		TIME COMPLETED:	05:20 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at approximately 9:32 a.m. The LPA met with Administrator Eugenia Abrigo and explained the reason for the visit.

At 9:47 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.

BEDROOMS: The LPA observed six resident bedrooms and one staff bedroom. All bedrooms were private with Bedroom #1 and Bedroom #4 containing a private bathroom. All resident bedrooms had an exit to the exterior. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet.

RESTROOMS: The facility has four (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. The resident bathroom has a shower with non-skid materials. The toilet and shower have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. In addition, restroom hot water measured under 120.0 degree F.

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. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interviews, the licensee did not comply with the section cited above as two (2) residents, whom are bedridden, are residing in non-ambulatory rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Administrator agreed to move one (1) resident into the bedridden room, the other resident will need to be reassessed or moved to a higher level of care.

Type A

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 in disinfectant wipes and nail polish remover where observed in the kitchen counter accessible to resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2023
	Plan of Correction
1 2 3 4	Administrator placed items in a secure location. Administrator stated they will conducted all staff training on section 87309 and submit training materials and attendees to CCL by 06/15/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observationa and interview, the licensee did not comply with the section cited above as two (2) out of three (3) staff members whom had fingerprint clearance but were not associated to this location, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/15/2023
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Ensure staff members are associated to this location by the end of 06/15/2023..

Type A

Section Cited

CCR

87465(h)(1)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: 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 five (5) out of 5 residents did not have their centrally stored medication up to date, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Administrator will update all 5 resident's centrally stored medication to reflect current medication on file. Administrator will submit documentation to CCL by 06/16/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as the Administrators License expired in 02/13/2023 and is not on the active or pending list on the CDSS website, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Administrator agreed to finish any CEU's and submit application for Re-Certification of Administrator License. Administrator will submit proof to CCl by 07/14/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

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 interview and record review, the licensee did not comply with the section cited above as 2 staff members did not complete their initial 40 hours of training, 20 hours ongoing training, 6 hours of dementia training, 16 hours hand on training, quarterly disaster training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2023
	Plan of Correction
1 2 3 4	Administrator will conduct the required training for 2 staff members. Administrator will submit documentation of completed training to CCL by 07/14/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 five (5) out of 5 residents did not have a Appraisal/Needs and Service Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Administrator agreed to complete 5 resident Appraisal, meet with resident's representative to sign and submit documentation of signed appraisals to CCL by 06/30/2023.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 2 residents did not have their LIC 602 Physician's Report in their chart, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have the residents obtain a completed LIC 602 for 2 residents. LIC 602's will be sent to CCL by 07/07/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/14/2023 05:03 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 2 out of 5 residents did not have their Tuberculosis results in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to have resident tested for Tuberculosis. Administrator will submit results to CCL by 07/07/2023.

Type B

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 5 out of 5 residents did not have their PRN Authorization Form which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send the PRN Authorization Letter to resident's physicians. Administrator will submit PRN Authorization form completed to CCL by 07/07/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/14/2023 05:03 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 5 residents did not have an active bed rail order, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Administrator agreed to reach out to resident's primary doctor to obtain bed rail orders.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

Page: 8 of 10

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: 06/14/2023

NARRATIVE

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system is hardwired and operated normally at the time of visit. Medications were observed to be locked in a closet by the kitchen and contained at least 30 days of worth of medication. The garage door was observed and contained a locked cabinet for laundry supplies. The backyard has a covered outdoor area equipped with furniture for client use. There were no bodies of water noted.

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.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Staff regarding the facility’s infection

control practices. Upon entry, the facility had 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. The facility’s cleaning protocol is
sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a
confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the
LPA reviewed facility’s policies and procedures as it pertains to infection control.

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

-- At 09:47 a.m. and 09:50 a.m., during facility tour, disinfectant wipes and nail polish remover was observed in the kitchen counter accessible to residents in care.

-- At 10:54 a.m., during resident file review, the Appraisal/Needs and Services for all resident was not observed/missing.

Continued on LIC 809 - C

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SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

Page: 9 of 10

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: 06/14/2023

NARRATIVE

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-- At 11:15 a.m., during resident file review, the LIC 602 Physicians Report for R1 and R2 indicated that R1 and R2 are bedridden. The Fire Inspection Safety Request indicated only Room #5 as a bedridden room. R1 and R2 are living in a non-ambulatory room. An immediate $500.00 civil penalty was accessed.

-- At 11:30 a.m., during resident file review, R3 and R4 did not have the LIC 602 Physician’s Report in their file.

-- At 11:35 a.m., during resident file review, R3 and R4 did not have their Tuberculosis results on file.

-- At 12:00 p.m., during resident file review, R1, R3, R4, and R5 did not have bed rail order in their resident file.

-- At 12:20 p.m., during medication review, LPA Ascencio did not observe 5 out of 5 resident’s PRN Authorization Letter in resident’s file

-- At 12:25 p.m., LPA Ascencio could not complete medication audit as 5 out of 5 residents did not have their Centrally Stored Medication Form updated with current medications.

-- At 01:00 p.m., during staff file review, LPA Ascencio observed an expired Administrator Certificate. Administrator stated they have not yet renewed their certificate but will be submitting documentation for re-certification. LPA Ascencio did not observe Administrator Eugenia Abrigo in the Active or Pending list on the CDSS.CA.GOV website.

-- At 01:35 p.m., during staff file review, S1 and S2 had fingerprint clearance but were not associated to the facility. LPA Ascencio checked the Guardian website and did not observe S1 and S2 associated to Woodland Hills Manor (191222545). A civil penalty of $500.00 per staff (R1 and R2) not associated to the facility was accessed.

-- At 01:40 p.m., during staff file review, LPA Ascencio did not observe S1 and S2 initial 40-hour training for staff, 20 hours ongoing annual training, Dementia Training, Medication Management Training and Quarterly Disaster Training Missing.

Exit interview conducted and a copy of the report and appeal rights were issued.

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SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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