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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 12/10/2021
Date Signed: 12/10/2021 05:15:52 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, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:WILLIAMS, CELESTEFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(818) 922-8980
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 8DATE:
12/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Eileen EsquivelTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20211203112208.

During today’s investigation, the LPAs observed that the facility did not have the required Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) for resident observation.

At 1:55 p.m., the LPAs observed wine accessible in the Discovery Room.

At 1:59 p.m., the LPAs observed gardening tools and planting soil in the outdoor courtyard.

During the file review, the LPAs audited the file for Staff #1 (S1) and noted that S1 was not associated to the community. After reviewing the Caregiver Background Check System, it was noted that S1 was separated from the community on 10/5/2021. A review of timecards and schedules for S1 confirmed that S1 worked at least eleven (11) days from 11/1/2021 – 11/31/2021 without appropriate clearance.

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



Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties assessed.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited

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87355(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above, as S1 was not associated to the facility since 10/5/2021 and has continued to work at the facility, which poses an immediate health and safety risk to residents in care.
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Type A
12/10/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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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 PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021
LIC809 (FAS) - (06/04)
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