195850173-9-14-2022-29-AS-ECAS-CJ9PVK-20220914113916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850173
Report Date: 09/14/2022
Date Signed: 09/14/2022 11:40:22 AM

Document Has Been Signed on 09/14/2022 11:40 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:	A'MORECARE HOME ASSISTED LIVING		FACILITY NUMBER:	195850173
ADMINISTRATOR:	ELKAYAM, EDVA		FACILITY TYPE:	740
ADDRESS:	23511 BERDON STREET		TELEPHONE:	(818) 635-3500
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Annette Amirkhanian-Administrator		TIME COMPLETED:	11:50 AM

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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 Administrator Annette Amirkhanian at 9:30 a.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Annette Amirkhanian at 9:50 a.m., to ensure there are no health and safety hazards.

BEDROOMS: There are six (6) bedrooms designated for resident use and one (1) bedroom designated for staff use. Each bedroom has a private half bath except for bedroom #2. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA observed accessible disinfectants and cleaning supplies under the bathroom sink in bedroom #1 and bedroom #6. Over-the-counter topical ointments, shaving cream and mouthwash were observed in bedroom #3 and bedroom #4. Restroom hot water measured between 110.8 and 120.3 degrees Fahrenheit between 9:53 a.m. and 10:57 a.m.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, medications, and chemicals were locked and inaccessible. Kitchen sink hot water measured 120.7 degrees Fahrenheit at 11:08 a.m.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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: A'MORECARE HOME ASSISTED LIVING	FACILITY NUMBER: 195850173
	VISIT DATE: 09/14/2022

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COMMON SPACES: The common spaces included the living room and dining area. The LPA observed a screened fireplace in the living room. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The LPA tested the fire alarm system at 10:48 a.m. and observed the system to be operating at the time of the visit. The fire extinguisher was observed to be full and last serviced on 11/3/21 and the 2^nd fire extinguisher was last purchased on 9/15/2021. The LPA observed required postings on the wall at the entrance. Flooring was checked for cleanliness and appeared in good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no accessible bodies of water noted. The LPA observed a storage unit containing additional supplies and gardening equipment.

INFECTION CONTROL: Upon entry, the facility had a central entry point for symptom screening, temperature
checks, and sanitation station. There was 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. The LPA reminded the
Administrator that masking protocols are still in place including vaccination requirements, visitation, and testing protocols.

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2022 11:40 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: A'MORECARE HOME ASSISTED LIVING	FACILITY NUMBER: 195850173
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the LPA observed accessible cleaning supplies, disinfectants and ointments, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Secure all accessible items and notify CCL no later than 9/15/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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