195850252-6-25-2024-29-AS-SURA-D6KTH6-20240625144409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850252
Report Date: 06/23/2024
Date Signed: 06/25/2024 02:44:49 PM

Document Has Been Signed on 06/25/2024 02:44 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:	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: 6	DATE:	06/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 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) Sandra Urena conducted a required annual inspection to the above facility. The LPA was greeted by staff, and LPA explained the reason for the visit. The staff contacted the Administrator Mary Ann Howe, and they arrived shortly thereafter.

The LPA and the staff toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards.
COMMON SPACES: 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. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced 2/6/2024. The facility smoke alarm system is hardwired and was operational. Medications were observed to be locked in a closet in the hallway between bedrooms #1 and #2.
KITCHEN: Kitchen knives are stored in a locked kitchen cabinet. The supply of dishes, utensils, pots,
pans and drink ware are adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the
refrigerator was maintained at 40*F.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four bedrooms for residents’ rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 112.8 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: FALLBROOK ELDERLY CARE LLC	FACILITY NUMBER: 195850252
	VISIT DATE: 06/23/2024

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
26
27
28
29
30
31
32

RECORDS: Records review began at 11:15 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:30 p.m.; medications are centrally stored and locked in a closet located between bedrooms 1 and 2; medications are labeled and checked for expiration dates. LPA Urena conducted a random selection of medications to be audited. The review of the Centrally Stored and Destruction Record (LIC 622) revealed that one medication Amlodipine (5mg/30) for R1 did not match the pills stored in the prescription bottle.

INFECTION CONTROL: The facility has 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 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.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/25/2024 02:44 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: FALLBROOK ELDERLY CARE LLC	FACILITY NUMBER: 195850252
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in one out of one medication,the review of the Centrally Stored and Destruction Record (LIC622) revealed that one medication Amlodipine (5mg/30) for R1 did not match the pills stored in the prescription bottle. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Administrator agreed to contract a qualified vendor/contractor to provide training to staff on medication storage, dispensing and verification of meds when received from pharmacy.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3