197606220-9-14-2022-31-AS-NRED-CJ9QZ6-20220914123614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606220
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:36:32 PM

Document Has Been Signed on 09/14/2022 12:36 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WOODLAND WEST HOMES III		FACILITY NUMBER:	197606220
ADMINISTRATOR:	BOZENA KOZBIAL		FACILITY TYPE:	740
ADDRESS:	22537 MARLIN PLACE		TELEPHONE:	(818) 594-7294
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 5	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Remedios Oster		TIME COMPLETED:	12:45 PM

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At 11:15 a.m. on 09/14/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 08/23/2019 for an annual visit. It is a single story building with 7 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents. The facility serves residents with dementia and uses surveillance cameras inside.

A sign was posted at the main entrance regarding the facility’s visitation policy. Inside, LPA observed postings for confidential complaints, Ombudsman contact, resident rights, COVID precautions, Emergency Disaster Plan, facility license and No Smoking - Oxygen in Use. LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, hand sanitizer, sanitizing wipes, and a visitor log. The visitor log tracked symptoms and temperature. 2 residents were observed watching television in the living room. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. Two closets in the hallway contained extra PPE and fresh linens. At approximately 11:30 a.m. LPA measured the room temperature to be 80 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The facility had a refrigerator and freezer in the kitchen and an additional freezer by the laundry room. The stove hood was clean. All other appliances were sanitary. Sharps were locked under the counter. An operable washer and dryer were located near the kitchen.

The facility had 6 resident bedrooms and 1 staff bedroom. The staff bedroom was clean and free of hazards. All resident bedrooms contained a chair, nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom exits were free of obstructions. Bedroom #3 and Bedroom #4 contained beds with full bed rails. Bed wheels were in the locked position.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND WEST HOMES III	FACILITY NUMBER: 197606220
	VISIT DATE: 09/14/2022

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The facility had 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction signs, trash cans with tight fitting lids, grab bars near the toilet and shower, and non-skid mats in the showers. Toilets died not have lids or seats, but assistive devices with lids and seats were located near the toilets. Staff confirmed all residents use the assistive devices. Both resident bedrooms had a drawer with a missing handle. LPA provided technical assistance to fix the missing handles.

All emergency exit paths were free from obstructions. The exit gate was unlocked with an inward facing latch. At 11:35 a.m. LPA observed 2 fully charged fire extinguishers near the kitchen and towards the rear of the facility. Both were last inspected on 05/24/2022. At 11:45 a.m. LPA tested the dual-functioning smoke and carbon monoxide detector to be operational. 3 out of 3 auditory alarms were on and functioning. Cleaning solutions were locked near the laundry room and in a storage chest outside.

LPA observed a maintained back yard and a covered patio area. A shed in the back yard and the garage contained assistive devices and incontinence supplies.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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