195850091-7-7-2022-29-AS-JAPL-CGNQM5-20220725121655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850091
Report Date: 07/07/2022
Date Signed: 07/07/2022 07:48:03 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/28/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220628124007

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: 20	DATE:	07/07/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Michael Owens		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident's room is not being cleaned regularly.
Resident's toilet paper supply is not being replenished regularly.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegations above. The LPA arrived at the facility at 10:32 a.m., and met with staff Michael Owens, Health Service Director. The LPA explained the reason for the visit.

The LPA and the staff conducted a physical plant tour from11:00 a.m. to 11:48 a.m., conducted records review at 12:10 p.m., and interviewed staff from 12:15 p.m., to 1:37 p.m.

Resident's room is not being cleaned regularly.
On the allegation, ‘Residents room is not being cleaned regularly’. It is alleged that during a visit, it was observed that the residents’ rooms were unkept, and staff neglected to keep the residents’ rooms clean. On 07/08/2022 at 11:00 a.m., the LPA and the staff conducted a tour of 20 residents’ rooms.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220628124007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/07/2022

NARRATIVE

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The LPA and the staff observed 16 bedrooms which appeared to be in clean condition, with adequate lighting, furnishings, and linens. Four (4) bedrooms were observed to have dirty floors, and debris. One bedroom was observed to have an approximate six-inch (6”), circular white colored (unknown) dried residue on the floor under the edge of the bed. One bedroom was observed to have a trail of dried urine on the floor (starting from the bedroom area through the hallway, and leading towards the front door of the room, and pooling by the closet area). LPA Urena interviewed staff form 12:15 p.m., to 1:37 p.m. The staff interviews revealed that housekeeping staff, and caregivers share cleaning duties, however, the deep cleaning duties are carried out by housekeeping staff. Additionally, staff stated that some residents do not allow staff to be in their rooms, while the residents are in the room, consequently staff may skip the cleaning for those rooms.

Based on the observations, and interviews conducted, the residents’ rooms are not being cleaned regularly. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Resident's toilet paper supply is not being replenished regularly.

On the allegation, ‘Residents’ toilet paper supply is not being replenished regularly’. It is alleged that during a visit it was observed that the residents’ toilet paper supply was not being replenished regularly. On 07/08/2022 at 11:00 a.m., the LPA, and the staff conducted a tour of the residents’ bathrooms. The LPA and the staff observed that four (4) out of the 20 bathrooms did not have toilet paper in the toilet paper dispenser. LPA Urena observed that the bathrooms do not have additional toilet paper supplies, other than what is hanging from the toilet dispenser. The staff interviews revealed that housekeeping staff, and caregivers are responsible for replenishing the toilet paper. However, some staff stated that the responsibility to replenish the toilet paper is the sole responsibility of the housekeeping staff. Additionally, staff stated that toilet paper is not kept in some bathrooms because some residents tend to unroll the paper rolls, and leave it laying on the floor.

Based on the observations, and interviews conducted, it was determined that residents’ toilet paper is not being replenished regularly. Therefore, the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (please refer to LIC 9099-D).

Exit interview was conducted with the Licensee's representative. The Report and Appeal Rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220628124007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/22/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The ED will post a cleaning schedule for housekeeping and caregiver duties in each room, which will show the date, time, name, and initials of the staff who conducted cleaning for each bedroom. The ED will send schedule to LPA as proof of correction.
	8 9 10 11 12 13 14	Based on the investigation, and interviews, the licensee did not comply with the section cited above, as four out of 20 bedrooms were observed unclean, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 07/22/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The ED will post a cleaning schedule for housekeeping and caregiver duties in each room, which will show the date, time, name, and initials of the staff who conducted cleaning for each bedroom. The ED will send schedule to LPA as proof of correction.
	8 9 10 11 12 13 14	Based on the investigation, and interviews, the licensee did not comply with the section cited above, as four out of 20 bedrooms were observed to lack toilet paper in the paper toilet dispenser, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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