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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607518
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:37:16 PM


Document Has Been Signed on 07/24/2024 03:37 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:VILLAGE CAREFACILITY NUMBER:
197607518
ADMINISTRATOR:ALIN S PAPAZIANFACILITY TYPE:
740
ADDRESS:12245 CALIFA STREETTELEPHONE:
(818) 516-1749
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY:6CENSUS: 4DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Alin PapazianTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 08:53 AM. LPA was greeted by Facility staff who contacted the facility administrator Alin S Papazian. Facility administrator arrived to the facility at approximately 10:00 AM Entrance interview conducted.

Beginning at 08:58 AM, the LPA, along with Facility staff 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:

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Cameras were observed in the common areas staff stated that the cameras record audio. A properly screened fireplace was noted in the living room. The LPA observed the fire extinguisher to be fully charged and purchased on 07/05/2024. Smoke detectors and carbon monoxide detectors were tested at 09:37 AM and were functional at the time of the visit.

KITCHEN & LAUNDRY: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPA observed one designated cabinet where knives and sharps are stored locked and inaccessible to residents. At 9:05 AM LPA inspected the refrigerator which was observed to contain expired milk.
LPA observed moldy vegetables stored on the kitchen counter that were discarded promptly. The laundry is located in a closet attached to the kitchen. Laundry supplies were observed to be in a locked cabinet inaccessible to residents in care.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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Document Has Been Signed on 07/24/2024 03:37 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: VILLAGE CARE
FACILITY NUMBER: 197607518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the exterior emergency exit gate was observed to be locked which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/25/2024
Plan of Correction
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Licensee will ensure exterior exit gates remain unlocked and will submit a statement of understanding confirming they have reviewed and understand CCR 87705(I)(2) to CCL no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 03:37 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: VILLAGE CARE
FACILITY NUMBER: 197607518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as employee training logs did not have the numbers of hours attended for each subject which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee will submit updated training documentation reflecting the correct number of training hours for each subject to CCL no later than POC due date
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as expired foods were observed in the kitchen refrigerator, in the vegetable basket, and in the emergency food supply which poses a potential health risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee will conduct an inspection of all food items located at the facility and will remove any expired items. Licensee will submit proof that items have been removed and will submit a statement of understanding that they have reviewed and understand CCR 87555(b)(8) to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 03:37 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: VILLAGE CARE
FACILITY NUMBER: 197607518

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(h)
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the exterior exit gate was observed to fail to self-latch which poses a potential safety risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee will contact an appropriate handyman and request a quote for repairs to the gate. Licensee will submit either a quote for repairs to and a planned completion date or proof of repairs made to CCL no later than POC due date.
Type B
Section Cited
CCR
87307(a)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as resident rooms contained cameras and common room cameras were identified by staff to record audio which poses a potential personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee has completed adendums to resident admission agreements and will submit an updated plan of operation outlining the use of cameras in common areas. Additionally licensee will submit an exception request to CCL to permit the use of cameras inside resident rooms. Licensee will submit the required documents to CCL no later than POC due date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE CARE
FACILITY NUMBER: 197607518
VISIT DATE: 07/24/2024
NARRATIVE
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Continued from LIC 809-C

BATHROOMS: There are three (3) bathrooms for resident use, one (1) of which is a private resident restroom located in bedroom three (3) and two (2) are shared resident restrooms. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured between108.7 and 118.4 degrees Fahrenheit, which is in compliance with regulation.

BEDROOMS: There are four (4) bedrooms in the facility; all are designated for resident use, including two (2) shared rooms, All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Cameras were observed in resident rooms. The closet light in resident bedroom three (3) was observed to be nonfunctional at the time of the visit.



OUTDOOR SPACE: The backyard has sufficient patio furniture including a table and chairs for resident use. Facility has one exit gate that was observed at 09:34 AM to be locked and failed to self-latch, LPA observed clear passageways for emergency exit use. LPA observed ongoing construction in the backyard.

GARAGE: The entry to the garage was observed to be locked and inaccessible to residents. Laundry supplies and chemicals are stored in a cabinet. Garage contained adequate emergency food and water supplies. LPA observed expired emergency food supplies that were discarded at the time of the visit.

RECORD REVIEW: Staff and resident records were reviewed 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. LPA reviewed employee trainings and observed the training logs to lack the number of hours completed for each training.

MEDICATION REVIEW: Began at 11:45AM. Medications for 2 (two) of five (5) residents were observed. All medications reviewed were documented and no deficiencies were observed during medication review.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE CARE
FACILITY NUMBER: 197607518
VISIT DATE: 07/24/2024
NARRATIVE
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Continued from LIC 809-C

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. Last emergency disaster drill was conducted 06/01/2024. The facility’s emergency disaster plan was outdated at the time of the visit and requires revision.

INTERVIEWS: LPA interviewed two (2) staff and one (2) residents. 2 (two) out of 2 (two) residents stated that there were not enough activities for them to participate in at the facility. Both staff were knowledgeable on their roles and responsibilities.

The following deficiencies were observed (See LIC 809-Ds) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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