195850240-6-29-2022-29-AS-ECAS-CFV3CV-20220629180833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 06/29/2022
Date Signed: 06/29/2022 06:09:36 PM

Document Has Been Signed on 06/29/2022 06:09 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VARIEL OF WOODLAND HILLS, THE		FACILITY NUMBER:	195850240
ADMINISTRATOR:	PAYNE, KEITH		FACILITY TYPE:	740
ADDRESS:	6233 VARIEL AVE		TELEPHONE:	(818) 651-6018
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	436	CENSUS: 0	DATE:	06/29/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Keith Payne-Executive Director		TIME COMPLETED:	06:15 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) Elsie Campos, Ashley Smith, and Emily Peraldi arrived for a pre-licensing visit at 9:00 a.m. The LPAs met with Executive Director Keith Payne and explained the reason for the visit. This is a new facility. A dementia program was included in the plan of operation. Component III was conducted in conjunction with this pre-licensing visit. An approved fire clearance was received on 06/16/2022, clearing the community for four hundred sixteen (416) non-ambulatory residents. All bedrooms cleared for bedridden use however this facility shall be limited to a maximum capacity of twenty (20) bedridden residents. facility has an approved Hospice Waiver for fifty (50) residents. Facility Layout: The facility has three (3) buildings, which are named Building A, Building B and Building C. At 9:20 a.m., a physical plant tour was conducted inside and out. The facility has three hundred thirty-six (336) units. Building B has a Memory Care Unit on the 7^th floor and there are three (3) delayed egress doors on 7^th floor. The resident rooms in the Memory Care Unit are single occupancy and have no appliances. Lighting in the rooms appeared adequate. The model rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. The rooms in Building A, Building B, and Building C (excluding the 7^th floor Memory Care Unit) are equipped with a refrigerator, microwave, and sink, and in-unit washer and dryer. The rooms in Building A, Building B and Building C are majority single occupancy, with the availability of double occupancy in some rooms. 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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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: VARIEL OF WOODLAND HILLS, THE	FACILITY NUMBER: 195850240
	VISIT DATE: 06/29/2022

NARRATIVE

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Building A has the following amenities and common areas: offices spaces, conference rooms, mail room and the bistro are located on the first floor. One (1) theater is located on the first floor and a second (2) theater is located on the second floor. The main kitchen and dining area are located on the second floor. The second-floor amenities include: art room, the tavern with locked cabinets, the marketplace, the activity/simulator room, wine cellar, outdoor terrace, and wellness center. The third floor has a covered outdoor area with outdoor furniture for resident use.

Building B has the following amenities and common areas: pet washroom, salon, activities/conservatory room and a community garden. Throughout Building B there are community rooms and a covered outdoor area for resident use located on the third floor. Building C has the following amenities and common areas: a wellness center with gym equipment, a yoga room, a juice bar, a physical therapy room, a massage room, a laundry room and a salon. There is an in-ground pool which is kept locked on the first floor of Building C.

Common Spaces: Regarding the pendant system, the system is activated in the resident bedrooms and restrooms. All systems go directly to a computer at the front desk and to hand-held devices. Designated staff carry a handheld device, which displays the location of the alarm that has been pulled. Staff also utilize walkie-talkies to communicate with staff accordingly. Pendants will also be offered as needed. There are cameras observed in exterior perimeter. The community’s smoke detectors and carbon monoxide detectors are hard wired and were installed within the past 12 months. The fire extinguishers are located on every floor in each building and were observed to be fully charged and serviced. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the hallways. The emergency telephone numbers are posted in the entryway. Other required postings are posted on the first floor of Building A, near the mailroom and the common hallway. The LPAs observed the Ombudsman Poster and DSS Complaint Poster throughout the community.

Kitchen: The community had a sufficient supply of seven-day nonperishable food at the time of the visit. Appliances in the kitchen were clean and appeared functional. Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents in the Bistro. Food is prepared in the main kitchen, which is located in Building A on the second floor and is delivered to the separate dining rooms.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

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: VARIEL OF WOODLAND HILLS, THE	FACILITY NUMBER: 195850240
	VISIT DATE: 06/29/2022

NARRATIVE

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Bathrooms: Bathrooms were equipped with grab bars near the toilet and shower/tub, and non-skid surfaces were observed in the shower/tub. During today's visit, water temperature was tested in all three buildings and ranged between 106 to 114 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit.

Files: Resident records will be stored in a locked cabinet in the Business Office and in the medication room, and staff records are stored in a locked cabinet in the Human Resources Room.

Medications: Medications for the main facility are found in Building B, in the third floor Wellness Center. There is a complete first-aid kit and a surplus of medical supplies. There are additional first aid kits throughout the community. There is a medication cart with double locking system for narcotics.

Grounds: Community has three vehicles for transportation needs – a seventeen (17) passenger bus, a six (6) passenger van, and a small SUV. There was a fountain observed in the courtyard; however, the community drained the water out of the fountain during the visit. There are approximately 275 parking spots available for residents and staff.

Infection Control: The community has a central entry point for symptom screening and temperature checks for staff, residents and visitors. There is hand sanitizer available throughout the community. The community has an adequate supply of Personal Protection Equipment (PPE) and the community is able to obtain additional supplies as needed. If needed, the community has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The community has a record of staff vaccinations and understands that they will need to maintain vaccination records for all residents that are vaccinated.

Physical plant is in compliance with Title 22 regulations at this time.

This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate and accept residents until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued 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: 06/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022

LIC809 (FAS) - (06/04)

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