197604780-12-4-2023-29-AS-BBAI-CY7UVC-20231204145456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604780
Report Date: 12/04/2023
Date Signed: 12/04/2023 02:56:02 PM

Document Has Been Signed on 12/04/2023 02:56 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:	VILLA MULHOLLAND II		FACILITY NUMBER:	197604780
ADMINISTRATOR:	RIMMA GORDON		FACILITY TYPE:	740
ADDRESS:	4501 SAN FELICIANO DR.		TELEPHONE:	(818) 348-3825
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	6	CENSUS: 6	DATE:	12/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Rimma Gordon		TIME COMPLETED:	03:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 10am. Upon arrival LPA met with Administrator Rimma Gordon and explained the reason for the visit. At approximately 10:30am, tour of the physical plant was conducted. The facility has seven (7) bedrooms and eight (8) bathrooms currently occupying (6) residents in six (6) private bedrooms. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, Hospice waiver for four (4). Living and dining room furniture were also checked. Dining room furniture were observed to be in good condition and appeared to be relatively clean. LPA observed (1) resident having breakfast in the dining room. The facility maintains a comfortable temperature. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were fully charged and last serviced on 01/20/2023. Kitchen area was sufficiently stocked with perishable and non-perishable food properly stored. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be kept in a locked drawer to the left of the sink. LPA observed the medication cabinet located next to the laundry area to be locked and inaccessible to residents. First aid kit is observed to be inaccessible to residents in care complete with tools and supplies. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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: VILLA MULHOLLAND II	FACILITY NUMBER: 197604780
	VISIT DATE: 12/04/2023

NARRATIVE

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LPA inspected all bedrooms and each were observed to properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Extra linens are kept in cabinets in the hallway nearest bedroom #1. LPA observed a sufficient supply of linen, personal hygiene supplies, PPE, First aid kit and supplies stored at this location as well. LPA observed staff bedroom in hallway to be empty and inaccessible to residents at this time.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured between 105 and 120 degrees Fahrenheit. There is enough clean linen available in stock at the linen cabinet.

The backyard of the facility has outdoor furniture with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The garage is attached to the home and has a living quarter for extra staff. LPA observed room to be empty at this time. The garage also serve as storage for additional perishable and non-perishable food, other supplies and old equipment storage. The garage was observed to be inaccessible to residents in care. Laundry area is located along the kitchen hallway leading to the garage. Laundry detergents, cleaning agents and other toxins are kept in the locked cabinet in the laundry area.

Records review began at approx. 11am, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be in order at this time.

Medications review began at approximately 1pm The medications are centrally stored in the medication cabinet located near the laundry room. Medications are properly documented on the centrally stored medications and destruction record.

Between 12:30pm - 1pm , LPA interviewed two (2) residents and three (3) staff.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: VILLA MULHOLLAND II	FACILITY NUMBER: 197604780
	VISIT DATE: 12/04/2023

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Continued from 809-C
The LPA spoke with Rimma regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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. If needed, the facility has the capacity to designate room #1 as a single isolation room if the facility has a confirmed case of a communicable disease. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

During the visit, LPA obtained an updated Limited Liability insurance.

Exit interview conducted and a copy of the report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC809 (FAS) - (06/04)

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