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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 09/12/2022
Date Signed: 09/12/2022 05:29:18 PM


Document Has Been Signed on 09/12/2022 05:29 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, THEFACILITY NUMBER:
195850240
ADMINISTRATOR:PAYNE, KEITHFACILITY TYPE:
740
ADDRESS:6233 VARIEL AVETELEPHONE:
(818) 651-6018
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:436CENSUS: 89DATE:
09/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Keith PayneTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20220826125755.

It was mentioned that Resident #2 (R2) had extensive care needs that were not communicated or discovered until R2 was admitted to the facility. The LPA audited R2’s file during today’s visit and noted that R2 was admitted on 8/20/2022 yet was assessed on 8/18/2022 and was deemed appropriate. However, despite what is documented on R2’s care plan as needing two people to assist with care and transfers, interviews and a review of End Of Shift Notes confirm that R2 oftentimes need more than two persons to safely assist R2. In addition, R2’s physician’s report dated 8/16/2022 indicated that R2 needs assistance with all activities of daily living. However, there were inconsistent statements shared regarding whether R2 can feed themselves. In this case, retaining R2 would be considered prohibited at this time if R2 needs assistance with all activities of daily living. R2's medical assessment and care plan do not accurately reflect R2's needs at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

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

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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Document Has Been Signed on 09/12/2022 05:29 PM - 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: VARIEL OF WOODLAND HILLS, THE
FACILITY NUMBER: 195850240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

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87463(a) Reappraisals.The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above as R2's care needs are not accurately reflected on the most recent care plan, which poses a potential health and safety risk to residents in care.
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Type B
09/23/2022
Section Cited

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87458(c) Medical Assessment. The licensee shall obtain an updated medical assessment when required by the Department.
This requirement is not met as evidenced by:
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Based on interview and record review, the licensee did not comply with the section cited above, as R2's medical assessment does not reflect R2's capacity for ADL care, which poses a potential health and safety risk to residents in care.
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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: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
LIC809 (FAS) - (06/04)
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