195850285-1-23-2024-29-AS-KDUK-CZS3U3-20240123173252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850285
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:33:06 PM

Document Has Been Signed on 01/23/2024 05:33 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 ASSISTED LIVING		FACILITY NUMBER:	195850285
ADMINISTRATOR:	ASATRYAN, YULIYA		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 395-9535
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Yuliya Asatryan		TIME COMPLETED:	05:38 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 Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:43AM. LPAs initially met with facility staff. Administrator was contacted via telephone and arrived at the facility at 12:20PM. Entrance interview conducted. Beginning at 12:25PM, the LPAs, along with 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 extinguisher is fully charged and last serviced on 03/27/2023. Hardwired smoke detectors were tested at 04:34PM, separate carbon monoxide detector was tested at 04:35PM and all were functional at the time of the visit. Fire pulls were tested during January 2023 fire inspection. No fire clearance concerns were observed during today's visit. BEDROOMS: There are six (6) total bedrooms in the facility; five (5) bedrooms are designated for resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. KITCHEN: The LPAs observed the kitchen. 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. Knives were locked in a kitchen drawer. At 12:35PM, LPAs observed cockroaches around the refrigerator, inside kitchen cabinets, and on the kitchen floor. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be properly furnished at the time of the visit. A fireplace was noted in the living room to be covered and Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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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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 ASSISTED LIVING	FACILITY NUMBER: 195850285
	VISIT DATE: 01/23/2024

NARRATIVE

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inaccessible to residents in care. At 12:00PM, LPAs observed a cockroach on the entry way table and a dead cockroach on the windowsill. Laundry area was observed in the hallway, with locked chemical storage.

BATHROOMS: There are two (2) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured and was in compliance with regulation. LPAs observed a dead insect taped to the restroom wall in the back common restroom.

GARAGE: Detached garage was observed locked and extra food, supplies, and emergency food and water, and chemical storage. LPAs observed expired macaroni and cheese in the outdoor food storage area.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There was a fountain observed on the back patio, which was inoperable, but did contain standing water from the recent rain. LPAs advised Administrator to remove standing water and ensure no further water is deposited in the fountain. At 12:58PM, LPAs observed both outdoor gates to not be self-closing or self-latching.

RECORD REVIEW: Resident records were reviewed for documents including, but not limited to: physician's report, needs and service appraisal, and personal rights. Two (2) of five (5) resident files observed contained an Admission Agreement for the closed facility previously located at this address. All remaining files observed were in compliance with regulation. Staff files were not reviewed during today's visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the
facility's emergency disaster plan. Last emergency drill was conducted on 01/11/2023. Emergency disaster plan was observed to be complete and updated annually, as required. Infection control plan was not reviewed during today's visit.

MEDICATION REVIEW: Not reviewed during today's visit.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FALLBROOK ASSISTED LIVING	FACILITY NUMBER: 195850285
	VISIT DATE: 01/23/2024

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INTERVIEWS: Interviews were not conducted during today's visit.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2024 05:33 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 ASSISTED LIVING	FACILITY NUMBER: 195850285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (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
1 2 3 4	Based on observation, the licensee did not comply with the section cited abovea, as cockroaches were observed in the space next to the refrigerator, in the kitchen cabinets, and on the kitchen floor, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator contacted a pest control company during today's visit and indicated they have scheduled the company Fumapest for a visit on Thursday 01/25/2024 and will come every month thereafter. Administrator will provide proof to CCL upon completion of Thursday's pest control visit.

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: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2024 05:33 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 ASSISTED LIVING	FACILITY NUMBER: 195850285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 (two) of 5 (five) resident records reviewed contained an Admission Agreement for the previous facility at this location, not the current licensed facility which poses a potential personal rights risk to persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain new Admission Agreements with the 2 residents identified and will provide proof to CCL by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the last emergency disaster drill was conducted on 01/11/2023, which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator agreed to conduct an emergency disaster drill and provide proof to CCL by POC due date. Administrator will also submit a training plan to include conducting an emergency disaster drill quarterly.

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: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2024 05:33 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 ASSISTED LIVING	FACILITY NUMBER: 195850285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. 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 as both outdoor gates are not self-closing or self-latching, which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 02/06/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide maintenance for the gates to ensure they self-close and self-latch. Administrator will provide proof of gates in compliance by POC due date.

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: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024

LIC809 (FAS) - (06/04)

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