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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850136
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:58:42 AM


Document Has Been Signed on 03/21/2022 11:58 AM - It Cannot Be Edited

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:FALLBROOK ESTATESFACILITY NUMBER:
195850136
ADMINISTRATOR:LACSON, DAVIDFACILITY TYPE:
740
ADDRESS:5515 FALLBROOK AVENUETELEPHONE:
(818) 712-0904
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
03/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary Ann HoweTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff at 9:15 a.m., and explained the reason for the visit. Administrators Mary Ann Howe and David Lacson arrived a short time therafter.

The LPA toured the physical plant areas inside and outside, with staff Desirie Dacut and Administrators Mary Ann Howe and David Lacson between 9:40 a.m and 10:40 a.m., to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. There are (4) four bedrooms designated for resident use and (1) one bedroom designated for staff use. Bedroom #3, Bedroom #4 and Bedroom #5 have a direct exit to the exterior. Accessible over-the-counter supplements were observed in the staff bedroom. At the time of observation staff room was unlocked. The LPA advised staff to keep over the counter supplements, medication and other personal care items for staff locked and inaccessible.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Restroom hot water measured 108.4 Fahrenheit at 9:45 a.m.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Accessible medications were observed in an unlocked kitchen cabinet. The LPA advised staff to keep all medications locked and in accessible at all times. Hot water measured 120.1 Fahrenheit at 9:51 a.m.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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: FALLBROOK ESTATES
FACILITY NUMBER: 195850136
VISIT DATE: 03/21/2022
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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness, living room and dining room furniture was observed to be in good condition, at the time of the visit. The LPA observed required postings in the hallway. Two fire extinguishers were observed to be fully charged and serviced on 3/21/2021. The LPA observed a screened fireplace in the living room. Smoke detectors are hardwired and interconnected. The LPA tested the smoke detectors between 10:37 a.m. and 10:39 a.m.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. A shed in the backyard was observed and contains additional PPE and resident supplies. No garage on the property.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA 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 does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.


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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/21/2022 11:58 AM - 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: FALLBROOK ESTATES
FACILITY NUMBER: 195850136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as resident medications were observed to be accesible in an unlocked kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
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The administrator agreed to do the following:
1. Ensure that the medications are stored in a locked cabinet. Plan of correction met at time of the visit.
Type A
Section Cited
CCR
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section as staff room was observed to be locked and over the counter nutritional supplements were accesible which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/21/2022
Plan of Correction
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The administrator agreed to do the following:
1. Ensure that staff bedroom remains locked and and all vitamins, nutritional supplements and medications are locked. Plan of correction met at time of the visit.

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: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3