195850252-5-30-2023-29-AS-AASO-CSBTES-20230530144026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850252
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:41:56 PM

Document Has Been Signed on 05/30/2023 02:41 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: 5	DATE:	05/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Mary Ann Howe		TIME COMPLETED:	03:00 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) Angel Ascencio conducted a required annual inspection to the above facility. The LPA met with Administrator Mary Ann Howe at 09:40 a.m. Entrance interview conducted. The LPA and Administrator Howe toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards. BEDROOMS: All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are five (5) total rooms - one (1) is a staff room, two (2) are shared, and 2 are private. RESTROOMS: There are three (3) 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. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. In addition, restroom hot water measured under 120.0 degree F. KITCHEN: Kitchen knives are stored in a locked closet by the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0F) and the refrigerator was maintained at 40F. Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 05/30/2023 02:41 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: FALLBROOK ELDERLY CARE LLC	FACILITY NUMBER: 195850252
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2023

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as Folic Acid 50 mg was not centrally stored which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/16/2023
	Plan of Correction
1 2 3 4	Administrator will conduct medication training on all staff who handle and help with the self administration of medication. Administrator will provide training materials and attendees to CCL by 06/16/2023.

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: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: 05/30/2023

NARRATIVE

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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social
distancing. The LPA observed the required postings in the common hallway. Fire extinguishers
were observed to be serviced within the last year. The facility smoke alarm system is hardwired and
operated normally at the time of visit. Medications were observed to be locked in a closet by the
kitchen and contained at least 30 days of worth of medication. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

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.

At 1:30 p.m., during medication review, LPA did not observed Folic Acid 50 mg inputted in the centrally stored records.

Exit interview conducted and a copy of the report and appeal rights were issued to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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