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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606861
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:51:14 AM


Document Has Been Signed on 01/04/2023 11:51 AM - 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:WEST HILLS CARE HOMEFACILITY NUMBER:
197606861
ADMINISTRATOR:ELAINE BOTEFACILITY TYPE:
740
ADDRESS:22956 INGOMAR STREETTELEPHONE:
(818) 888-9573
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 3DATE:
01/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elaine BoteTIME COMPLETED:
11:59 AM
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At 11:00 a.m. on 01/04/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and staff toured the facility inside and out. The facility was last visited on 01/24/2022 for a complaint visit. It is a single story building with 4 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 2 may be bedridden. Hospice waiver approved for 1 resident. The facility serves residents with dementia. 3 out of 3 auditory alarms were on and functioning during today’s visit. Surveillance cameras in common areas were observed.

Upon entry, LPA observed signs posted at the main entrance for the facility’s masking and visitation policies. A sign showing “No smoking – Oxygen in use” was also posted. Once inside, LPA observed additional postings for the facility’s COVID policies, facility sketch, Administrator certificate, facility license, Ombudsman contact, confidential complaint contacts, emergency disaster plan, personal rights, house rules, rights of resident councils, and theft and loss policy. LPA was screened for infectious disease upon entry. The screening station contained a visitor log, digital thermometer, surgical masks, N95 masks, gowns, sanitizing wipes, and hand sanitizer. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 11:02 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. The facility had 4 bedrooms. Bedroom #1 and Bedroom #3 were private. Bedroom #2 and Bedroom #4 were shared. All bedrooms contained a nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #4 was vacant. A linen closet in the hallway contained an adequate supply of fresh linens. The facility had 3 bathrooms. Resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:05 a.m. LPA measured the water temperature in Bathroom #1 to be 105.6 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. At 11:10 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/11/2022. Surfaces were sanitary.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WEST HILLS CARE HOME
FACILITY NUMBER: 197606861
VISIT DATE: 01/04/2023
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The stove hood needed cleaning, and staff noted they were in the middle of cleaning the kitchen before LPA arrived for inspection. Sharps and cleaning solutions were locked below the counter top. Medications were locked in an office area with resident files. The laundry area contained detergents and two operational appliances. The laundry area was locked. The back yard was maintained and contained a basketball hoop, workout equipment, and patio furniture in good condition. The patio furniture was shaded by an umbrella. In the living room and Bedroom #2, LPA observed family visiting with residents. All emergency exit paths were free from obstructions. At 11:14 a.m. LPA tested the smoke detector to be operational. At 11:15 a.m. LPA tested the carbon monoxide detector at the front to be operational.

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 HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC809 (FAS) - (06/04)
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