195850339-7-17-2023-29-AS-MARO-CTTTVX-20230717150441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850339
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:08:30 PM

Document Has Been Signed on 07/17/2023 03:08 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:	INN AT THE PARK VENTURA		FACILITY NUMBER:	195850339
ADMINISTRATOR:	ANGUIANO, ROSE		FACILITY TYPE:	740
ADDRESS:	21200 VENTURA BLVD		TELEPHONE:	(818) 884-7100
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 157	DATE:	07/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Rose Anguiano		TIME COMPLETED:	03:10 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) Martha Arroyo conducted a pre-licensing visit to the above noted facility. Upon arrival, the LPA met with Administrator, Rose Anguiano as this is a change of ownership application from Inn at the Park Ventura #197609623 to Inn at the Park Ventura #195850339. A dementia program was included in the plan of operation. Entrance interview. At 10:15 a.m., a physical plant tour was conducted inside and out. The facility is two-story. An approved fire clearance was received, clearing them for one hundred and ninety (190) non-ambulatory residents and ten (10) bedridden residents. Facility has an approved fire clearance for bedridden residents in rooms: #102, #103, #118–#124, #140, #142, #144, and #146. The facility offers both private and shared resident bedrooms. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, mattress, and clean linen, which includes pillowcases, blanket, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are no staff rooms as the facility has 24-hour care and supervision. All rooms were free of odors. All window screens were clean and maintained in good repair. Bathrooms are located in each resident room. The resident bathrooms have a shower with non-skid materials and the toilet and shower have grab bars. The hot water temperature was tested in random resident bathrooms in assisted living and memory care unit between 10:27 a.m. and 11:15 a.m. and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. Resident records are stored in the social worker's office and staff records are stored in the human resources office. Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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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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: INN AT THE PARK VENTURA	FACILITY NUMBER: 195850339
	VISIT DATE: 07/17/2023

NARRATIVE

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Report Continued from LIC 809...

Medications are centrally stored and locked in the medication room on the first floor. The first aid supplies were complete, including a current version of a first aid manual. They were stored in the medication room. Kitchen knives are stored in the kitchen inaccessible to residents in care. The supply of dishes, utensils, pots, pans, and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit, and the refrigerator was maintained at 40 degrees Fahrenheit. The supply of perishable and nonperishable food is adequate. There are no pesticides or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Cleaning supplies, laundry detergent, and disinfectants are kept locked inside the storage rooms. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and games and/or activity supplies in the library and activities room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were observed in the hallways. All stairwells are equipped with sturdy hand railings and evacuation chairs. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There are three (3) delayed egress doors approved for the memory care unit. Egress doors were tested and operable at the time of visit. The facility has emergency lighting in place. All resident rooms have a heater which is able to heat rooms to a minimum of 68 degrees Fahrenheit; and all resident rooms have their own air conditioner and is able to cool the room to a comfortable range, not to exceed 85 degrees Fahrenheit. Common areas have central air conditioning maintaining temperature at 74 degrees Fahrenheit. The facility smoke alarm system is hard wired. The facility has a fire alarm and sprinkler system in place. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. All fire extinguishers are fully charged and last serviced on 10/05/2022. The facility has two (2) laundry areas which are located on the first floor. The supply of extra bed and bath linens is adequate. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in each floor. The emergency telephone numbers are posted by the entrance. Other required postings are posted throughout the facility. The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use. The entire property is fenced. There are no bodies of water on the premises at the time of visit.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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: INN AT THE PARK VENTURA	FACILITY NUMBER: 195850339
	VISIT DATE: 07/17/2023

NARRATIVE

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Report Continued from LIC 809C...

Comp III conducted with the Administrator.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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