195850091-8-7-2024-29-AS-ABAN-D7WVA4-20240807161518

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 08/07/2024
Date Signed: 08/07/2024 04:19:37 PM

Document Has Been Signed on 08/07/2024 04:19 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:	PRESERVE AT WOODLAND HILLS, THE		FACILITY NUMBER:	195850091
ADMINISTRATOR:	MICHAEL OWENS		FACILITY TYPE:	740
ADDRESS:	6221 FALLBROOK AVENUE		TELEPHONE:	(747) 226-5834
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	60	CENSUS: 40	DATE:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Trevin Willis		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Angela Barutyan and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:47AM. LPAs met with staff and Executive Director (ED) Trevin Willis and explained the reason for the visit.

Beginning at 12:48PM, the LPAs, along with the ED 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:

COMMON AREAS: Upon entry to the facility, there is a central entry point for check in with staff. There are no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which are fully charged and last serviced 04/19/2024. Activities are offered and all activity rooms and common spaces appeared clean and in good repair. Fire alarm and sprinkler systems are tested annually and were last tested on 11/20/2023.

KITCHEN: LPAs inspected the kitchen at 01:09PM. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures. Appropriate hand washing signs were posted throughout the kitchen. Facility has a set menu and 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.

BEDROOMS: The LPAs observed 10 (ten) random resident bedrooms throughout the facility. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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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Document Has Been Signed on 08/07/2024 04:19 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
WOODLAND HILLS N.ASC, 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: 08/07/2024

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 that 3 (three) out of 5 (five) staff did not have their 40 hours of initial training which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff who require 40 hours initial training will have it completed by 09/06/2024. Administrator will email training logs to CCL by 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2024 04:19 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
WOODLAND HILLS N.ASC, 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record, the licensee did not comply with the section cited above in that 2 (two) out of 5 (five) staff did not have their 20 hours of annual training which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that all staff who require 20 hours annual training will have it completed by 09/06/2024. Administrator will email training logs to CCL by due date.

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: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: PRESERVE AT WOODLAND HILLS, THE	FACILITY NUMBER: 195850091
	VISIT DATE: 08/07/2024

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BATHROOMS: Restrooms were observed to contain nonskid mats and grab bars by the showers and toilets. LPAs measured water temperatures in 5 (five) resident bathrooms and were between 107.8 and 113.2 degrees Fahrenheit, which is within the required range.

OUTDOOR SPACE: The LPAs toured the outside area of the facility and observed appropriate outdoor furniture in the courtyard, with a covered shaded area for residents. Parking is available. Area is maintained clean.

RECORD REVIEW: LPAs began record review at 10:10AM. LPAs reviewed 5 (five) staff files for documents including, but not limited to: health screening, TB test, training records, fingerprint clearance, and CPR/First-Aid certification. LPAs observed all 5 (five) staff files to have insufficient training with 3 (three) out of 5 (five) staff files missing 40 hours initial training and 2 (two) out of 5 (five) staff files missing 20 hours annual training. Resident files will be reviewed during annual continuation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required.

MEDICATION REVIEW: Will be reviewed during annual continuation.

INTERVIEWS: During today's visit, LPAs interviewed 4 (four) staff and 5 (five) residents.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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