195850091-8-14-2023-29-AS-ZCHN-CUQ3CD-20230814180747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/14/2023
Date Signed: 08/14/2023 06:08:22 PM

Document Has Been Signed on 08/14/2023 06:08 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:	TREVIN R WILLIS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 51	DATE:	08/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Trevin Willis		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Zabel Chochian conduct a required annual visit. LPA met with Executive Director Trevin Willis and discussed the annual inspection protocol.

Between 12:30pm-2:30pm, the Executive Director and LPA toured the physical plant areas inside, random resident rooms and the outside; during the tour randomly selected residents were interviewed. Common Areas: Upon entry to the facility, there is a central entry point for check in with staff. 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 71 degrees Fahrenheit. There are fire extinguishers throughout the facility, which were charged and last serviced 6/2/2023. Activities are offered. All activity rooms and common spaces appeared clean and in good repair. Common restrooms observed stocked with soap and paper towels; hot water temperature maintained within required range (105-120 degrees Fahrenheit). Resident Rooms: The resident bedrooms were properly furnished with a bed, chair, night stand, sufficient lighting for each resident, closet space and chest of drawers. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed resident bathrooms clean, properly supplied and had functional fixtures. Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Facility has a set menu, and also offers an alternate menu for residents. Food is prepared based on the resident’s diets. Snacks and beverages are available for residents throughout the day. The emergency supply food and water observed in stored separately. 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. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. No deficiencies at this time.

Annual visit will continue to a later date for records review. Exit interview conducted.Copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

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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