195850423-7-19-2024-29-AS-VCOY-D7BUKT-20240719153941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850423
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:39:58 PM

Document Has Been Signed on 07/19/2024 03:39 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:	IVY PARK AT WOODLAND HILLS		FACILITY NUMBER:	195850423
ADMINISTRATOR:	O'GRADY, PATRICE		FACILITY TYPE:	740
ADDRESS:	20461 VENTURA BLVD.		TELEPHONE:	(818) 346-9046
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	127	CENSUS: 68	DATE:	07/19/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Patrice O'Grady		TIME COMPLETED:	03:30 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 Analysts (LPAs) Valeria Conway and Brian Balisi conducted a pre-licensing visit to this property at 09:45AM. LPAs met with Executive Director (ED), Patrice O’Grady, and explained the reason for the visit. This application is for a Change of Ownership Application (CHOW) currently operating with Facility license #197608478 and the current licensed facility has residents in care. The applicant has obtained fire clearance for One hundred and nineteen (119) non-ambulatory which eight (8) bedridden residents. There is a pending hospice care waiver. The facility is a (five) 5 story building including an underground garage. At approx. 10:30 A.M., a physical plant tour was conducted inside and out. There are fire sprinklers and fire doors throughout the facility. The kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean. 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. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Trash cans had tight fitting lids. No flies or other vermin were observed. At 10:35 A.M. hot temperature water measured at 113 degrees Fahrenheit. Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 195850423
	VISIT DATE: 07/19/2024

NARRATIVE

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Continued from LIC 809

At approximately 10:50 A.M, LPAs inspected eight (8) randomly selected rooms in all four (4) floors including the memory care unit. All resident rooms are set up with beds, nightstands, 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. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all eight (8) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a brake room for staff at the facility. For nocturnal (NOC) shift, there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers have grab bars.

LPAs inspected the common areas throughout the facility including the Activity room, Lobby, reading room, lounge, café, health and fitness center. All the rooms have been appropriately furnished. There is a dedicated area for the posting of required documents throughout the facility. The common areas were observed to be properly furnished and relatively clean at the of the visit. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. All exits in Memory care have functioning auditory devices and were operational at the time of the visit.There is an evacuation chair in each stair well on each side of the building.

Resident records review began at 11:55 A.M. Six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Staff records review began at 12:30 P.M, Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Daily vehicle inspection list and California Highway Patrol Inspection report was revieweds. Last emergency disaster drill was conducted 07/09/2024.

Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 195850423
	VISIT DATE: 07/19/2024

NARRATIVE

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Continued from LIC-809C

All records were observed to be in order at this time. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. the main two (2) first aid kits were observed in the memory care director office and the health service office. Medications are stored in a medication cart which are kept in each floor and inaccessible to residents in care.

Medications review began at approximately 12:45 P.M. Medications are properly documented on the centrally stored medications and destruction record.

Entry/exits were free of obstructions. The outdoor areas were clean and free of hazards. The patios and balconies observed have proper furnishings. There were no bodies of water noted.

Component III was conducted in conjunction with the visit.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Executive Director.

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.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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