197601827-7-19-2024-29-AS-ABAN-D7BW5U-20240719165942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601827
Report Date: 07/19/2024
Date Signed: 07/19/2024 05:00:18 PM

Document Has Been Signed on 07/19/2024 05:00 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:	WALNUT ACRES RESIDENTIAL CARE		FACILITY NUMBER:	197601827
ADMINISTRATOR:	SUSAN CALDWELL		FACILITY TYPE:	740
ADDRESS:	22907 OXNARD STREET		TELEPHONE:	(818) 348-2210
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	07/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Susan Caldwell		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:01AM. LPA met with Licensee/Administrator Susan Caldwell. Entrance interview conducted.

Beginning at 9:03AM, the LPA, along with Licensee/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 extinguishers are fully charged and recently serviced on 04/02/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 09:43AM and were not operating, however, staff changed batteries at 9:46AM and all were functional at the time of the visit after staff changed the battery. LPA observed exit alarms by doors but were not able to be turned on.

BEDROOMS: There are 5 (five) total bedrooms in the facility; 4 (four) are designated as private resident rooms and 1 (one) is a shared resident room. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #2 is single occupancy with no private bathroom and no exit to the exterior. Bedroom #3 is a shared room containing two beds, two closet spaces with outdoor access and a shared bathroom. Bedroom #4 is single occupancy with a private bathroom and a direct exit to the exterior. Bedroom #5 is single occupancy with a private bathroom and a direct exit to the exterior. 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 linens; 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. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
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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Document Has Been Signed on 07/19/2024 05:00 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: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 that 1 (one) staff member was not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2024
	Plan of Correction
1 2 3 4	Administrator associated employee during the time of the visit. POC is cleared.

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: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2024 05:00 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: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in that only 1 (one) out of 5 (five) staff possesssed a valid CPR and first aid training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that staff get CPR and first aid training and submit proof to CCL no later than 07/26/2024.

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 that 4 (four) out of 5 (five) staff did not have a health screening report, which poses a potential health and safety rights risk to persons in care.
	POC Due Date: 08/02/2024
	Plan of Correction
1 2 3 4	Administrator will ensure that staff go to an approved physician for a health screening. Administrator will submit health screening reports to CCL no later than 08/02/2024.

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: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/19/2024 05:00 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: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in that 6 (six) cans of garbanzo beans, 1 (one) bag of lettuce, and 1 (one) jar of mayonnaise were expired which posed a potential health and safety rights risk to persons in care.
	POC Due Date: 07/20/2024
	Plan of Correction
1 2 3 4	Staff discarded all expired food items during the time of the visit. POC is cleared.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 that 2 (two) out of 5 (five) residents did not have an updated physicians report for 2024, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/26/2024
	Plan of Correction
1 2 3 4	Administrator will submit a statement of understanding of section 87458 to CCL by 07/26/2024. Administrator will also ensure that resident 1 goes to the physician for her appointment date of 08/05/2024. Administrator will also ensure to make appointments in a timely manner for the future.

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: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2024

I acknowledge receipt of this form and understand my 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: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
	VISIT DATE: 07/19/2024

NARRATIVE

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BATHROOMS: There are 5 (five) total bathrooms. 4 (four) bathrooms are for resident use and 1 (one) is kept locked for staff use and medication storage. Knives and sharps are stored locked in staff bathroom by the kitchen. Restrooms were observed to contain nonskid surfaces. Grab bars by the showers and toilets were observed in the bathrooms. The water temperature was measured in 2 (two) resident bathrooms and measured between 111.1 and 116.6 degrees Fahrenheit, which is within the required range. LPA observed a storage space closet in hallway containing clean linens for resident use.

COMMON AREAS: This includes the living room, dining room, den, and sitting room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed surveillance cameras in common room which do not record audio.

OUTDOOR SPACE: The backyard has covered patio areas with patio furniture including tables and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. LPA observed a guest house in the backyard where Licensee/Administrator lives. LPA observed the front gate to be unlocked and self-latching, as is required.

KITCHEN: Kitchen was observed to be clean. 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. Cleaning supplies, washer and dryer, and detergents are located in the locked laundry room adjacent to the kitchen. At 9:12AM, LPA observed 6 (six) cans of expired garbanzo beans dating between April to May 2024 in the hallway pantry. At 9:18AM, LPA observed a bag of expired lettuce dated 07/09/2024 and mayonnaise dated 07/14/2024 in the kitchen refrigerator. Staff discarded all expired items immediately.

GARAGE: A1:54PM, LPA toured the detached garage which has been converted to the facility office. The garage was free of obstructions.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are not conducted quarterly, however, Licensee/Administrator conducted a fire drill at 11:50AM during the time of the visit.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
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)

Page: 10 of 11

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: WALNUT ACRES RESIDENTIAL CARE	FACILITY NUMBER: 197601827
	VISIT DATE: 07/19/2024

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RECORD REVIEW: LPA began record review at 9:53AM. LPA reviewed 5 (five) out of 5 (five) resident files and 5 (five) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 3 (three) out of 5 (five) resident files and 4 (four) out of 5 (five) staff files were missing documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. During medication review around 12PM, LPA observed alterations to medication labels, which is not in compliance with federal regulations.

INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents. 1 (one) staff member was not associated with the facility and left premises, but Licensee/Administrator was able to associate staff during the time of the visit.

During today's visit, LPA obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty were issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
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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