197602257-2-14-2024-31-AS-NRED-D2FU84-20240214142056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602257
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:21:09 PM

Document Has Been Signed on 02/14/2024 02:21 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MARBLE TERRACE II		FACILITY NUMBER:	197602257
ADMINISTRATOR:	GODLEWSKA, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	19030 MIRANDA AVENUE		TELEPHONE:	(818) 345-8971
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Bozena Kozbial		TIME COMPLETED:	02:25 PM

NARRATIVE

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At 10:20 a.m. on 02/14/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit.

LPA and administrator toured the facility inside and out. No immediate health and safety risks were observed.

The facility was last visited on 07/17/2023 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents. Approved hospice waivers for one (01).

At 10:45 a.m. LPA conducted a records review of resident and personnel records. During review of resident records, LPA noted the medical assessment’s of Resident #1 (R1) and Resident #2 (R2) both denoted they were bedridden. The administrator reviewed the documents with LPA and stated the medical assessment of R2 was done quickly and incorrectly. The administrator assured LPA that R2 was non-ambulatory and confirmed several other errors on R2’s assessment. The administrator agreed to obtain a new medical assessment for R2 as soon as possible. The administrator called the licensee at 2:00 p.m.to discuss the care of R1 since the facility’s fire clearance allows only non-ambulatory residents. This deficiency related to the facility operating beyond the capacity of its fire clearance is cited on the attached LIC 809-D page. A $500 immediate civil penalty is assessed today for the violation of the facility’s approved fire clearance. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

At the main entrance, LPA observed a maintained front yard with stairs leading to the main entrance. Postings were observed for confidential complaint contacts, ombudsman contacts, personal rights, rights of resident councils, nondiscrimination notice, neighborhood grievance procedure, emergency disaster plan, facility license, facility sketch, administrator certificate, and a blank copy of an admission agreement. Signs showing “No smoking – Oxygen in use” were posted at the main entrance and on the doors of Bedroom #4 and Bedroom #5.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 02/14/2024 02:21 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE II	FACILITY NUMBER: 197602257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 two (02) out of six (06) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to obtain an updated and accurate medical assessment for Resident #2 (R2) and either schedule an inspection to obtain a new fire clearance or create a relocation plan to relocate Resident #1 (R1) by the POC due date in order to abide by the facility's current current fire clearance.

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE II	FACILITY NUMBER: 197602257
	VISIT DATE: 02/14/2024

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The facility has six (06) bedrooms. Bedroom #6 is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Beds in Bedroom #1 and Bedroom #3 had half bed rails. The bed in Bedroom #5 had full bed rails.

The facility has four (04) bathrooms. One (01) bathroom is designated for staff, and three (03) others are shared for residents. All bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mats or surfaces in the showers.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen, garage, and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the stove. Cleaning solutions were locked below the sink.

A washing machine and dryer were located adjacent to the kitchen. Both were in working order. Detergents were locked above the washer.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair and exercise equipment. At 11:40 a.m. LPA measured the room temperature to be 71 degrees Fahrenheit. Medications were locked in a hallway closet. Additional food supplies were stored near Bedroom #3. An office space was locked and contained resident files. A linen closet near Bedroom #4 contained an adequate supply of fresh linens, PPE, and hygiene supplies.

All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing, inward facing latches. At approximately 11:45 a.m., a smoke and carbon monoxide detector was tested and operational. At approximately 11:50 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/05/2023. At approximately 12:00 p.m. auditory alarms were tested and noted to be on and functioning

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and resident plants. The garage contained an extra refrigerator and freezer and extra supplies.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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