195850246-7-10-2024-29-AS-ABAN-D72SR4-20240710140545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850246
Report Date: 07/10/2024
Date Signed: 07/10/2024 02:06:03 PM

Document Has Been Signed on 07/10/2024 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WALNUT GARDEN III		FACILITY NUMBER:	195850246
ADMINISTRATOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	12802 COLLINS STREET		TELEPHONE:	(818) 624-1918
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 5	DATE:	07/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Izhak Illouz		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Angela Barutyan, Kelly Dulek, and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 9:49AM. LPAs met with Licensee/Administrator Izhak Illouz. Entrance interview conducted.

Beginning at 9:54AM, the LPAs, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and recently serviced on 02/06/2024. At 10:15AM, LPAs observed the side gate to be locked at the time of the visit which poses a fire clearance concern. Hardwired combination smoke and carbon monoxide detectors were tested at 10:55AM and all were functional at the time of the visit. LPAs observed a fire door separating the living room from resident bedrooms which failed to self-close at the time the test was conducted.

BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff room was observed to be locked.

BATHROOMS: There are 6 (six) bathrooms for resident use. 1 (one) is designated for shared resident use and the other 5 (are) are private resident restrooms. Restrooms were observed to contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in all resident bathrooms and measured between 111.7 and 118.8 degrees Fahrenheit, which is within the required range. Room #7 belonging to resident #1 (R1) was observed to have missing grab bars in the shower and by the toilet. Staff placed temporary suction grab bars which fell off at the time of the visit.

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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 07/10/2024 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN III	FACILITY NUMBER: 195850246
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 in that the emergency exit gate was locked and the fire door did not self-close when smoke detectors were tested which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 07/11/2024
	Plan of Correction
1 2 3 4	Administrator contacted the fire door installer during the time of the visit and staff unlocked the emergency exit gate. Administrator agreed to ensure that the fire door will remain closed until repairs are completed. Administrator will submit proof of repairs to CCL upon completion.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN III	FACILITY NUMBER: 195850246
	VISIT DATE: 07/10/2024

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Exit doors contain alarms and were functional at the time of the visit.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including tables and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. An outdoor shed containing emergency water supply was observed to be locked and inaccessible to residents.

KITCHEN/GARAGE: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knife drawer was observed to have a non-functioning lock, however, no knives were observed to be in the drawer at the time of the visit. Cleaning supplies are located in a locked under-sink cabinet. Washer and dryer were observed to be next to the refrigerator. Medications were observed to be in a locked kitchen cabinet. The garage on the property has been converted to a residential unit with a separate address which is not attached to the house.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/05/2024.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 6 (six) staff files observed contained all documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents.

During today's visit, LPAs obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty were issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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