197603849-10-26-2022-29-AS-EPEI-CKKT2P-20221026142103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603849
Report Date: 10/26/2022
Date Signed: 10/26/2022 02:21:38 PM

Document Has Been Signed on 10/26/2022 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MANOR CARE FACILITY		FACILITY NUMBER:	197603849
ADMINISTRATOR:	SOMERA, ERLINA		FACILITY TYPE:	740
ADDRESS:	7768 ALLOTT AVE.		TELEPHONE:	(818) 785-7047
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91402
CAPACITY:	4	CENSUS: 3	DATE:	10/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Erlina Somera, Licensee		TIME COMPLETED:	02:30 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 Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:35 p.m., the LPA was greeted and screened by the Licensee. This annual had a specific emphasis on infection control practices and procedures. At 12:53 p.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:35 p.m., hot water measured at 108.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced within the year. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 1:34 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:21 p.m., hot water measured at 105.1-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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: MANOR CARE FACILITY	FACILITY NUMBER: 197603849
	VISIT DATE: 10/26/2022

NARRATIVE

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OUTDOOR SPACE: At 1:24 p.m., the LPA observed the back patio. There is a gate on the side of the house designated for an emergency exit. At 1:28 p.m., the LPA observed the front gate, however the latch was padlocked. The LPA informed the Licensee that it must be removed. The garage is attached to the house and remains locked and inaccessible to residents.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee 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. The LPA observed a 30-day 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.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See LIC 9099-D).

Exit interview conducted. Report issued and a copy of the report and appeal rights was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/26/2022 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR CARE FACILITY	FACILITY NUMBER: 197603849
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(6)

87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night...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 the self-latching gate which exits to the front was padlocked, which poses an immediate health, safety or personal rights risk to persons in care..
	POC Due Date: 10/27/2022
	Plan of Correction
1 2 3 4	The Licensee has agreed to do the following: 1. The padlocked needs to be removed within 24 hours. The Licensee with send a picture to the LPA.

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) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC809 (FAS) - (06/04)

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