197607495-8-22-2024-29-AS-ABAN-D8DQP4-20240822122006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607495
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:22:23 PM

Document Has Been Signed on 08/22/2024 12:22 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CHATEAU LE PETITE III		FACILITY NUMBER:	197607495
ADMINISTRATOR:	BELINDA DOLINSKY		FACILITY TYPE:	740
ADDRESS:	24312 CARIS STREET		TELEPHONE:	(818) 610-1082
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dexter Olavario		TIME COMPLETED:	12:45 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) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:45AM. LPA met with Head Caregiver (HC) Dexter Olavario. Administrator Belinda Dolinsky could not be on site at the time of the visit, but Dexter Olavario was designated to sign in their place. Entrance interview conducted.

Beginning at 9:52AM, the LPA, along with the HC toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and were last serviced 06/06/2024. Hardwired smoke detectors and carbon monoxide detector in kitchen were tested at 11:17AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating.

COMMON AREAS: This includes the living room, physical therapy room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. At 09:53AM, LPA observed a fireplace in the living room not appropriately screened. Facility is maintained at a comfortable temperature. LPA observed surveillance cameras in the common areas. LPA observed storage space closets in hallway containing clean linens for resident use.

BEDROOMS: The facility consists of eight (8) total bedrooms, of which six (6) are designated for single-resident use and two (2) are designated for staff use. All resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff bedrooms were observed and were occupied by staff.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

Document Has Been Signed on 08/22/2024 12:22 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 in that water temperatures in resident bathrooms measured between 138.0 F-142.1 degrees Fahrenheit which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Staff lowered the water temperature on the water tank during the time of the visit. Administrator will submit a 5 day water log to CCL by 08/29/2024.

Type B

Section Cited

CCR

87307(d)(7)

Personal Accommodations and Services

(7) Fireplaces and open-faced heaters shall be adequately screened. 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 in that the fireplace in the living room is not adequately screened which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Administrator will screen the fireplace and send proof to CCL by 08/29/2024.

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) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 08/22/2024 12:22 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that three out of five residents did not have an updated appraisal which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Administrator will reappraise residents and send proof to CCL by 09/05/2024.

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) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
	VISIT DATE: 08/22/2024

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
26
27
28
29
30
31
32

BATHROOMS: There are six (6) total bathrooms, of which five (5) are attached to resident rooms and 1 (one) is for common use. Restrooms were observed to contain nonskid mats and grab bars by the showers and toilets. Water temperatures in resident bathrooms were measured between 138.0 and 142.1 degrees Fahrenheit between 09:58AM-11:22AM, which is outside of the required range.

LAUNDRY ROOM: LPA observed the laundry room adjacent to the staff rooms. Laundry room has a washer and dryer and locked cleaning supplies.

KITCHEN/GARAGE: LPA inspected the kitchen at 10:05AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed emergency food and water supply in the pantry next to the kitchen. Food was stored at appropriate temperatures. The locked garage is accessed through the kitchen. LPA observed an additional refrigerator/freezer and cleaning supplies in the garage.

OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) side pathway is used as an emergency exit which was free of obstruction and had a self-closing and self-latching gate.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/27/2024.

RECORD REVIEW: LPA began record review at 10:20AM. LPA reviewed 5 (five) out of 5 (five) resident files and 4 (four) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) out of five (5) resident files were missing documents. Staff files were complete and had no missing documents.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III	FACILITY NUMBER: 197607495
	VISIT DATE: 08/22/2024

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
26
27
28
29
30
31
32

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the kitchen. LPA began medication review at 11:24AM and medications for 2 (two) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law

INTERVIEWS: During today's visit, LPAs interviewed two (2) staff and one (1) family member of resident. Residents did not want to be interviewed.

During today's visit, LPA obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela Barutyan	TELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6