195850091-8-26-2021-29-AS-SURA-C69TA8-20210826143307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/26/2021
Date Signed: 08/26/2021 02:34:13 PM

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:	WILLIAMS, CELESTE		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(818) 922-8980
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 0	DATE:	08/26/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Celeste Williams		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	The prelicensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 10:30am and met with Executive Director, Celeste Williams and Assistant Executive Director, Celeste Lozano. This is a new facility application, for 60 residents. A Hospice Waiver has been requested for 10 residents. The entrance of the facility is equipped with electronic thermometer and system for self -health screening for infection control, and signing in. Hand sanitizer is available and is mechanically dispensed. Masks are available at front desk. The physical plant was toured inside and out. The facility has been cleared for 60 non-ambulatory residents, of which, 10 can be bedridden residents. The facility has 50 private resident bedrooms and 10 shared room(s). Rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms appeared adequate. There are no staff rooms – awake night staff only. There are three restrooms in the hallway in the common areas. There are two staff restrooms located by the office area. Each resident’s bedroom has a bathroom. The residents’ bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment in the living room and dining area. Resident and staff records are stored in a filing cabinet, which is currently located in the business manager’s office. Medications will be stored in locked cabinets in the medication room #31. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the kitchen, laundry room and front office and medication room.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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: 08/26/2021

NARRATIVE

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Kitchen area is accessible through key coded panel. Kitchen knives are stored in a locked drawer in the kitchen. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the house keeping room. There are two fireplaces in the living/common area rooms. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit.

The facility smoke/carbon monoxide alarm systems are battery operated. Rooms #101, 105, 107, 110, 115, 120, 125, 130, 135, 140, 145 and 150 were tested and all smoke/carbon monoxide alarm systems were in operating condition. There are 10 fire extinguishers throughout the facility. They are charged, and were maintained in 7/2021. Hot water was tested in 10 residents’ bathrooms; it measured 107 degrees Fahrenheit. The laundry area is located behind locked doors. The supply of extra bed and bath linens is adequate. Extra incontinency supplies are stored in the laundry room. There is a functioning telephone on the premises. Emergency exiting plans/sketches are posted at the entrance of the facility and by the egress doors. Emergency telephone numbers are posted at the front desk. Infection control and other posters are posted throughout the facility and hallways.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the center of the facility, with tables and chairs where residents can sit. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions. The parking area is in the front of the building and not accessible by residents.

Applicant completed Component III orientation at this time.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

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