195850120-1-24-2024-29-AS-EPEI-CZT3KX-20240124171953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850120
Report Date: 01/24/2024
Date Signed: 01/24/2024 05:20:33 PM

Document Has Been Signed on 01/24/2024 05:20 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:	ADVANCED HOME CARE SENIOR LIVING		FACILITY NUMBER:	195850120
ADMINISTRATOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	5826 JUMILLA AVE		TELEPHONE:	(818) 340-4652
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Catherine Santos, Administrator		TIME COMPLETED:	05:25 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 Analysts (LPAs) Emily Peraldi and Valeria Conway arrived at the facility unannounced to conduct a required annual visit. At 10:35 a.m., the LPAs met with staff and explained the reason for the visit. At 10:57 a.m., the Administrator, Catherine Santos arrived at the facility. At 11:20 a.m., the LPAs, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. BEDROOMS: The facility is a single-story residential home with six (6) bedrooms, five (5) for resident use and one (1) for staff use and four (4) bathrooms. The LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting 11:25 a.m., hot water measured between 105.7 and 112.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the restroom cabinets. KITCHEN: The LPAs observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:56 a.m., hot water measured at 114.9-degree Fahrenheit. Medications are located in a locked filing cabinet in the kitchen. Laundry units are located next to the kitchen. Continued on LIC-809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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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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: ADVANCED HOME CARE SENIOR LIVING	FACILITY NUMBER: 195850120
	VISIT DATE: 01/24/2024

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OUTDOOR SPACE: At 11:41 a.m., the LPA observed the back and front patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. There are two unlocked storage sheds, however no hazardous or dangerous items were observed in the sheds. The property has an ADU behind the facility.

COMMON AREAS: The LPAs observed common areas to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and last serviced on 08/07/2023. At 1:30 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. All exits have functioning auditory devices and were operational at the time of the visit. Facility telephone was observed during the time of the visit.

Starting at 11:32 a.m., the LPAs conducted interviews with four (4) out of five (5) residents and three (3) staff.

RECORD REVIEWS: Between 12:00 p.m. and 1:20 p.m., the LPAs conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order. The Administrator’s certificate is active and expires on 05/03/2024. Copy of valid liability insurance and Facility Emergency Plan was provided to the LPAs during the visit. A copy of LIC 9020A, LIC 308, LIC 500 and Infection Control Plan was provided to the LPAs as well.

Between 2:38 p.m. and 4:00 p.m., the LPAs conducted a review of medication and medication documentation with staff for four (4) out of five (5) residents and observed that all medications were properly documented and assisted with as prescribed.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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