197602743-2-16-2023-29-AS-KDUK-CP4RPS-20230216121226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602743
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:12:42 PM

Document Has Been Signed on 02/16/2023 12:12 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:	LEISURE LIVING		FACILITY NUMBER:	197602743
ADMINISTRATOR:	MICHELLE MAURER		FACILITY TYPE:	740
ADDRESS:	5608 ROCK CREEK RD.		TELEPHONE:	(818) 426-0099
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:13 AM
MET WITH:	Dilbert Puno		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, LPA met with facility staff Dilbert Puno and explained the reason for today's visit. Administrator Michelle Maurer was contacted via telephone at 10:15AM and was unavailable at the time of the visit. Administrator verbally authorized facility staff Dilbert Puno to sign today's report. Entrance interview conducted.

At 10:29AM, LPA, along with facility staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Common Areas: These included the living rooms and dining areas. The common areas were checked for cleanliness and good condition. All common areas were properly furnished at the time of the visit. Medications were observed to be locked in a cabinet in the hallway next to garage door.

Smoke alarms were tested at 10:42AM and were functional at the time of the visit. Carbon monoxide detector was tested at 10:46AM and functioned properly. The fire extinguisher was fully charged and purchased 09/30/2022.

Bedrooms: There were four (4) bedrooms total with one (1) bedroom designated for staff use. All three (3) resident bedrooms are designated as shared rooms. All bedrooms for resident use were properly furnished and had appropriate bedding and linens. LPA observed staff room to be locked at the time of the visit.

Bathrooms: There were two bathrooms designated for resident use. Both bathrooms appeared clean,
Report continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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: LEISURE LIVING	FACILITY NUMBER: 197602743
	VISIT DATE: 02/16/2023

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Continued from 809

properly supplied and had functional fixtures, including grab bars and non-skid surfaces. Water temperature was checked in the common hallway restroom at 10:36AM and measured at 126.7 degrees Fahrenheit. Water temperature was tested in the private resident restroom at 10:49AM and measured at 122.1 degrees Fahrenheit.

Kitchen: The kitchen appeared clean. Kitchen refrigerator was observed to be non-functional at the time of the visit. Staff indicated it is broken and they are currently utilizing the refrigerator located in the garage. LPA found a sufficient amount of perishable food stored in the fridge and non-perishable food properly stored in a pantry on the exterior of the kitchen. Knives and sharps are stored in a locked cabinet.

Surrounding Grounds: The garage is attached to the home. Emergency/disaster and PPE supplies are properly stored in the garage inaccessible to the residents at this time. The laundry area was located in the garage as well with cleaning supplies inaccessible to residents at this time. LPA observed a shaded outdoor area for resident use, patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe any obstructions to emergency exits at this time. Side gate door is self latching and no bodies of water noted during this visit.

INFECTION CONTROL: During today’s visit, LPA called and spoke with the Administrator at 10:54AM regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided and sent to Administrator via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/16/2023 12:12 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE LIVING	FACILITY NUMBER: 197602743
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as water temperature was measured in the common hallway restroom at 126.7 degrees Fahrenheit at 10:36AM and at 122.1 degrees Fahrenheit in the shared resident restroom at 10:49AM, which poses an immediate safety risk to persons in care.
	POC Due Date: 02/24/2023
	Plan of Correction
1 2 3 4	Administrator agreed to adjust the hot water temperature today. Administrator also agreed to measure water temperature daily at varying times of the day for 7 days and record the temperature on a log to be submitted to CCL by POC due date.

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: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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