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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602669
Report Date: 02/23/2024
Date Signed: 02/23/2024 05:22:35 PM


Document Has Been Signed on 02/23/2024 05:22 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:LEISURE LIVINGFACILITY NUMBER:
197602669
ADMINISTRATOR:MICHELLE MAURERFACILITY TYPE:
740
ADDRESS:6156 HEDGEWALL DR.TELEPHONE:
(818) 879-9900
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:TIME COMPLETED:
05:30 PM
NARRATIVE
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At 10:10 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by House Manager Blaire Soriano and informed them of the reason for the visit. Administrator Michelle Maurer was unable to be present during the visit and authorized Blaire Soriano to review and sign the report.

At 10:26 a.m. the LPA conducted a tour of the physical plant with the House Manager to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of five (5) resident bedrooms, and two (2) restrooms. The LPA observed one (1) fire extinguisher which was fully charged and last purchased on 09/21/2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: At 10:32 a.m. the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. The LPA observed bedrooms #2, #3 and #4 with exit doors obstructed. Bedroom #2 had a nightstand and a chair obstructing the exit door to the outside. Bedroom #3 had a dresser and a portable ventilator obstructing the exit to the outside, and a nightstand obstructing the door between bedroom #3 and bedroom #4. The door between bedroom #3 and #4 is an exiting door for bedroom #4.

Report will continue on LIC809-C.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: LEISURE LIVING
FACILITY NUMBER: 197602669
VISIT DATE: 02/23/2024
NARRATIVE
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Bathrooms: The LPA observed all bathrooms, properly supplied, and had functional fixtures. The LPA observed grab bars and non-skid floors in all bathrooms. At 10:44 a.m. water temperature in the outside restroom was measured at 128.9 degrees Fahrenheit. At 10:58 a.m. water temperature in the resident’s restroom in room #1 was measured at 127.2 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen.
The garage: The LPA observed the garage where the washer and dryer are held. The garage is used as storage. The garage is locked.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Record Review: At 11:07 a.m. a review of facility files was initiated. Facility records are stored in a locked closet. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 02/05/2023). The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) out of six (6) resident files. Files were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The Appraisal/Needs and Services Plans (ANS) for one resident was noted with two dates, the LPA could not verify if the ANS was from 2023 or 2022, however the House Manager confirmed it was dated 2023. Otherwise, all resident records were in order. The LPA reviewed five (5) of seven (7) staff files. Staff files and Administrator’s file were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA identified that one (1) of five (5) staff did not have TB test results on file. Otherwise, all staff records were in order.
Interviews: The LPA conducted two (2) resident Interviews and two (2) staff interviews. No immediate concerns were voiced.
Medications: At 2:30 p.m. a medications review was initiated for two out of five residents and the following was observed. The medications were stored in a locked closet and inaccessible to the residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. During Resident #1 and Resident #2 ‘s (R1, R2) audit, the LPA observed PRN medication for both residents, however the LPA did not observed a PRN authorization letter from their physicians.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/23/2024 05:22 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: LEISURE LIVING
FACILITY NUMBER: 197602669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two of two bathrooms, as both bathrooms had a temperature higher than 120 degree F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Facility designee agreed to adjust water temperature to the required temperature between 105-120 degrees F and agreed to record water temperatures at various times of the day for a 5-day period and submit the log to CCL by POC due date.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in three exit doors as they were obstructed during the time of the visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Plan of correction has been met. Facility designee moved the nightstands, dresser, chair and portable fan and all exit doors were cleared.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/23/2024 05:22 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: LEISURE LIVING
FACILITY NUMBER: 197602669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one of five staff as they did not have a TB test result on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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The facility designee agreed to do the following:
1. Obtain the TB results for S1. Submit proof by 03/08/2024

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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/23/2024 05:22 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: LEISURE LIVING
FACILITY NUMBER: 197602669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Resident #1 and Resident#2 take PRN medication and did not have a PRN authorization letter on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Facility designee agreed to obtain a PRN authorization letter for all clients with PRN medication. Also Administrator shall develop a PRN log to document medication dispensed according to regulation. Submit copy of the PRN authorization letter and log by 3/08/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5