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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850240
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:53:54 PM

Document Has Been Signed on 07/18/2023 04:53 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:JOYCE AQUINOFACILITY TYPE:
740
ADDRESS:6233 VARIEL AVETELEPHONE:
(818) 651-6018
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 436CENSUS: 239DATE:
07/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Joyce AquinoTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angel Ascencio and Ashley Morgan conducted a Annual Continuation on the above facility. The initial annual was conducted on 06/12/2023. LPAs met with Director of Resident Care Services (DRCS) at 09:15 a.m. Entrance interview conducted.

Resident Files: The LPAs observed ten (10) resident files. All files contained the proper documents necessary to stay in compliance.

Staff Files: The LPAs observed ten (10) staff files. All staff files contained the proper documentation to be in compliance within state regulations.

At 1:40 p.m. the LPAs interviewed five (5) staff members. No immediate concerns noted during the interviews.
MEDICATIONS: Medications review began at 12:00 p.m. The LPAs reviewed medications for five (5) residents. Facility maintains a medication room, and medications are kept locked and inaccessible. For one resident (Resident #1) had an as-needed medication (Acetaminophen) that was administered two (2) times since 6/2/2023; however, staff documented that R1 was assisted with this PRN medication one (1) out of two (2) times. For three out of five residents (Resident #2, Resident #3, Resident #4), the pill count was off during the medication audit.
At 1:37 p.m., the LPAs observed accessible medications in an unlocked office. The office was locked at the time of observation.
At 4:00 p.m., the LPAs observed expired bread, expired milk, uncleaned kitchen area, food (bread, pies) not covered putting at risk for contamination, and cleaning substances stored within the food storage area.

Continue on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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 07/18/2023 04:53 PM - It Cannot Be Edited


Created By: Angel Ascencio On 07/18/2023 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a medication audit, the licensee did not comply with the section cited above as 3 out of 5 resident medication pill count was not concuring with documentation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Administrator will conduct a medication audit on the 3 resident medications. Administrator will submit a letter to CCL indicated the audit was completed.
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 medication was accessible in an unlocked office which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2023
Plan of Correction
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Medication was secured during today's visit. Administrator will conduct all staff training on ensuring medications are kept inaccesssible at all time.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2023 04:53 PM - It Cannot Be Edited


Created By: Angel Ascencio On 07/18/2023 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply with the section cited above 3 out of 5 Centrally Stored Medication and Destruction Records was not up to date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator will conduct a medication audit on the 3 resident medications. Administrator will submit a letter to CCL indicated the audit was completed.
Type B
Section Cited
CCR
87555(b)(23)

(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.
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 pies, bread and vegetables where not properly covered which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Food items were properly covered during today's visit. Administrator will conduct kitchen staff training on section 87555(b)23).
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


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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: 07/18/2023
NARRATIVE
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 07/18/2023 04:53 PM - It Cannot Be Edited


Created By: Angel Ascencio On 07/18/2023 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(24)
General Food Service Requirements
(24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.

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 disinfectant wipes were obserevd in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Disinfectant wipes were secured in a different location. Administrator will conduct kitchen staff training in section 87555(b)(24).
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 the kitchen area was observed unclean and not sanitary which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2023
Plan of Correction
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Administrator will submit a plan on how they will maintain the kitchen area in clean and sanitary. Administrator will submit documentation of plan to CCL by 8/4/23.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


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