197606861-1-30-2025-31-AS-PKHN-DDEU3C-20250130141320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606861
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:14:00 PM

Document Has Been Signed on 01/30/2025 02:14 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WEST HILLS CARE HOME		FACILITY NUMBER:	197606861
ADMINISTRATOR/ DIRECTOR:	ELAINE BOTE		FACILITY TYPE:	740
ADDRESS:	22956 INGOMAR STREET		TELEPHONE:	(818) 888-9573
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Elaine Bote - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:15 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	On 1/30/25 an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver Mercedita Malano, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. Shortly after the Administrator, Elaine Bote arrived and helped with physical plant tour and staff/residents’ files. During today's visit, LPA conducted a physical plant walk through at approximately 11:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and of which fire clearance approved for two (2) Bedridden. Facility also has a hospice waiver for one (1) resident. There are four (4) bedrooms in the facility and all bedrooms are designated for residents’ use. Bedrooms observed to be appropriately furnished. LPA observed rooms to have clean bedding sheets, pillowcase, blankets, mattress pads, which are in good condition. All bedrooms have appropriate lighting. LPA observed obstruction in front of the exit door in bedroom #4. There are three (3) bathrooms in the facility of which two (2) are designated for residents’ use and one (1) for staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 11:30 to be 118°F. Extra towels and linens were readily available inside the linen cabinet located in the hallway. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were present on all exit doors and all the signals were functional. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) fire extinguisher located in the kitchen that was last purchased on January 1st, 2025. Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WEST HILLS CARE HOME	FACILITY NUMBER: 197606861
	VISIT DATE: 01/30/2025

NARRATIVE

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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked kitchen cabinet under the sink and inaccessible to residents in care. Extra emergency food was properly stored inside the industrial cabinet located within the kitchen and the dining room areas. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:45am to be 69°F. No tripping hazards found throughout the facility.

MEDICATION: LPA observed centrally stored medication and First Aid kit locked in the kitchen cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Facility has two (2) staff for AM shift and two (2) awake caregivers for PM shift.

COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. Facility has land line, LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located in the separate locked area next to the second living room. LPA observed chemicals and detergents were properly stored, locked and inaccessible to residents in care. LPA discussed the importance of keeping potentially dangerous items locked at all times.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area was available for residents to rest and enjoy outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is a garage in the property, which is currently being used for storage.

FILE REVIEW: Between 12:00pm to 1:00pm, LPA reviewed records and files of three (3) residents and three (3) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WEST HILLS CARE HOME	FACILITY NUMBER: 197606861
	VISIT DATE: 01/30/2025

NARRATIVE

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A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility.
Facility also provides activities to the residents.
An emergency exit plan/sketch along with other posting requirements are posted on the wall in the living room.

Medications Review: At approximately 1:30pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts.

LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate, and copy of the facility license.

Citation issued during this visit and appeal rights were provided. See LIC809-D

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui Khurshudyan	TELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/30/2025 02:14 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WEST HILLS CARE HOME	FACILITY NUMBER: 197606861
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services: d) The following space and safety provisions shall apply to all facilities: 6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, during visit on 1/30/2025, the licensee did not comply with the section cited above to ensure the emergency exit door/passageway in room # 4 was free of obstruction, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Licensee/administrator cleared the emergency exit door from the obstruction during the annual inspection. LPA cleared the deficieny on 1/30/25.

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.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Perchui Khurshudyan	TELEPHONE: (818) 439-7073
	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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