195850091-8-24-2022-29-AS-ASMH-CHM2YG-20220824174842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/24/2022
Date Signed: 08/24/2022 05:49:34 PM

Document Has Been Signed on 08/24/2022 05:49 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:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	EILEEN ESQUIVEL		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 18	DATE:	08/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Eileen Esquivel		TIME COMPLETED:	06:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Director Eileen Esquivel and informed them of the reason for the visit.

At 2:15 p.m., the Executive Director and LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Food is prepared based on the resident’s diets. The menu was posted, and the facility offers an alternate menu. Snacks and beverages are available for residents throughout the day. The emergency supply food and water is sufficient.

Common Areas: Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 70 degrees Fahrenheit. There are fire extinguishers throughout the facility, which were charged and last serviced 8/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Common Restrooms: The LPA observed common restrooms throughout the community. Hand-washing signs were observed in the common restrooms. Restrooms were fully stocked with soap and paper towels. During today’s visit, the LPA tested water temperature and it registered at 116.9 degrees Fahrenheit.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/24/2022

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Outside areas: The LPA toured the outside area of the facility. The LPA observed appropriate outdoor furniture in the courtyard, with a covered shaded area for residents. Parking is available. Area is maintained clean. The LPA tested the delayed egress doors and they were operable at the time of the visit.

Records: The LPA reviewed five staff records at 2:45 p.m. Records were in order. The LPA reviewed five resident records at 3:30 p.m. Records were in order.

Medications: A medication review was conducted for two residents at 4:10 p.m. Medications were not documented on the centrally stored medication and destruction record for one of two residents (Resident #1).

Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA observed signs in the community that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The licensee has submitted the required Infection Control Plan and required addendums in a timely manner. The community's policies and procedures pertaining to infection control were adequate.

During today’s visit, the LPA obtained an updated copy of the resident roster, staff roster, and up-to-date liability insurance.

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.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2022 05:49 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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(A-F)

87465(h)(6)(A-F) Incidental Medical and Dental Care.The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited above, as medications were not documented on the Centrally Stored Medications and Destruction Record for one out of two residents (R1), which poses a potential health and safety rights risk to persons in care.
	POC Due Date: 08/25/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Audit R1's medications, and ensure all medications are properly documented on the Centrally Stored Medications and Destruction Record within the next 24 hours. 2. Conduct an in-service with staff, reviewing the policies and procedures as it relates to documentation. Submit completion by 8/26/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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