195850102-12-21-2021-29-AS-EPEI-C9WU36-20211221141259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850102
Report Date: 12/21/2021
Date Signed: 12/21/2021 02:36:55 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:	COLONY - SHERMAN OAKS 1, THE		FACILITY NUMBER:	195850102
ADMINISTRATOR:	MARASIGAN, CLAUDETTE		FACILITY TYPE:	740
ADDRESS:	5416 TYRONE AVENUE		TELEPHONE:	(818) 652-8038
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Claudette Marasigan		TIME COMPLETED:	02:38 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	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 11:30 a.m. LPA was greeted and screened by staff. At 11:30 a.m., LPA met with Administrator Claudette Marasigan. This annual had a specific emphasis on infection control practices and procedures. At 11:56 a.m. LPA and Administrator began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations. OUTDOOR SPACE: LPA observed the backyard, which has a covered outdoor area for resident use. There is a latch on the side gate for emergency exits. KITCHEN: At 11:57 a.m. LPA observed the kitchen/dining area. Knives are stored in the locked kitchen cabinet. Kitchen appliances were in operable condition except for the dishwasher. The Administrator explained that the dishwasher stopped working two weeks ago and will be fixed and will send the scheduled maintenance date to LPA. At 1:10 p.m. LPA observed staff washing dishes. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 12:48 p.m. LPA observed hot water to be measured at 115.3-degree Fahrenheit. Continued on LIC 809C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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: COLONY - SHERMAN OAKS 1, THE	FACILITY NUMBER: 195850102
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above as the dishwasher was inoperable which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2021
	Plan of Correction
1 2 3 4	Licensee will send picture proof of the dishwasher maintenance or send a receipt of a newly purchased dishwasher to LPA by 12/31/2021.

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) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: COLONY - SHERMAN OAKS 1, THE	FACILITY NUMBER: 195850102
	VISIT DATE: 12/21/2021

NARRATIVE

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Continued from LIC 809.

COMMON AREAS: At 12:00 p.m., LPA observed common areas to be relatively clean and properly furnished.

At 1: 07 p.m. LPA observed the fire extinguisher charged and last serviced on 11/12/2021.
Medications and first aid kits are in a locked medication cabinet located in the laundry room. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the laundry room.
Required postings were observed in the entryway. All exits had a functioning auditory device.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 11:40 a.m. – 1:30 p.m., LPA conducted Infection Control mitigation module with Administrator.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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