195850252-6-28-2022-29-AS-ECAS-CFTVFF-20220628162353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850252
Report Date: 06/28/2022
Date Signed: 06/28/2022 04:24:18 PM

Document Has Been Signed on 06/28/2022 04:24 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:	FALLBROOK ELDERLY CARE LLC		FACILITY NUMBER:	195850252
ADMINISTRATOR:	HOWE, MARY ANN		FACILITY TYPE:	740
ADDRESS:	5515 FALLBROOK AVENUE		TELEPHONE:	(818) 712-0904
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	06/28/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	MaryAnn Howe		TIME COMPLETED:	04:30 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 Analyst (LPA) Elsie Campos arrived at the facility announced at 10:15 a.m. to conduct a pre-licensing inspection. The LPA met with applicant MaryAnn Howe. This is a change of ownership application from Fallbrook Estates (#195850136) to Fallbrook Elderly Care LLC (#195850252). The current census is for six (6) residents, the facility currently has four (4) residents. The fire clearance was granted on 03/17/2022; in which all rooms were cleared for non-ambulatory clients and in which a bedridden person is permitted in Bedroom #1. Applicant successfully completed Component II on 04/07/2022 and completed Component III on 6/28/2022 with LPA Elsie Campos. The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in the cabinet under the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. BEDROOMS: There are five bedrooms in the facility; the facility has four (4) bedrooms for resident use, and one (1) staff room. The staff room is kept locked. Room #1, Room #3 and Room #5 have direct access to the outside. Resident room #5 and room #2 are shared rooms. Resident room # 1 and room #3 are private resident rooms. Lighting in the rooms appeared adequate. Four out of four resident rooms were set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. 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: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: FALLBROOK ELDERLY CARE LLC	FACILITY NUMBER: 195850252
	VISIT DATE: 06/28/2022

NARRATIVE

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BATHROOMS: There are three (3) full bathrooms. There are two (2) bathrooms for resident use; the full bathroom in the hallway is designated for staff and guests. Resident bedroom #1 and #5 have an attached bathroom that is shared between bedroom #1 and bedroom #5. Resident bedroom #3 has an attached bathroom for private use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature measured in bathrooms measured between 108.5 – 114.0 degrees Fahrenheit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and a cabinet with games and activities for resident use. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There is a fireplace in the living room, which is appropriately screened. The fire extinguisher was fully charged and last serviced 5/17/2022. There is a functioning telephone on the premises.

Emergency exiting plans/sketch are posted in the facility hallway. Emergency telephone numbers are posted in the facility hallway. Other required postings are posted in the hallway and upon entry into the facility.

MEDICATIONS: Medications are in a locked closet located in the hallway and a locked cabinet in the kitchen to the right of the stove. The first aid supplies were complete.

FILES: Resident and staff records are stored in a filing cabinet which is currently located in the living room.

LAUNDRY: The laundry area is in the hallway, directly across from the designated staff room which is locked and inaccessible to residents in care.

GROUNDS: The facility has a covered car port. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time. The LPA observed a locked storage unit in the back yard containing additional incontinence supplies, cleaning supplies and Personal Protective Equipment (PPE).

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: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: FALLBROOK ELDERLY CARE LLC	FACILITY NUMBER: 195850252
	VISIT DATE: 06/28/2022

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INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility 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 under the new license number 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.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

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