197607880-2-8-2024-29-AS-BBAI-D29UXU-20240208145854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607880
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:59:56 PM

Document Has Been Signed on 02/08/2024 02:59 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOUNTAINVIEW AT EISENBERG VILLAGE		FACILITY NUMBER:	197607880
ADMINISTRATOR:	ADAM PENA		FACILITY TYPE:	741
ADDRESS:	6440 WILBUR AVENUE		TELEPHONE:	(818) 654-5534
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	216	CENSUS: 102	DATE:	02/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Adam Pena - Administrator		TIME COMPLETED:	03:30 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 Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 09:30am. Upon arrival LPAs met with Executive Director Adam Pena and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The LPAs began the inspection in the kitchen/food service area. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPAs inspected the common areas throughout the facility inside and out. All areas have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced Jan, 31, 2024. At approximately 10:07am LPAs inspected nine (9) randomly selected bedrooms throughout the four (4) occupied floors. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPAs observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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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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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 02/08/2024

NARRATIVE

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continued from 809
At approx. 10:11am, LPAs observed the water temperature above 120 degrees Fahrenheit in four (4) resident bathrooms on the first floor. Maintenance staff lowered temperature during the inspection. At approx. 1pm, LPA observed the water temperature to still be above 120 degrees Fahrenheit.
The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit from the second floor to the fourth floor. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. At 10:19am, LPAs activated a resident pendant, and observed staff respond in approx 5 mins. During the inspection LPAs observed, evacuation chairs in each stairwell.

On the basement level, LPAs observed a movie theater, two (2) locker room areas for male and female employees along with a food storage pantry. LPAs observed a sufficient supply of PPE stored in the storage pantry. Additional non-perishable foods were also observed in the food storage pantry. The parking garage was accessible from the basement, but locked from the outside and monitored by security. LPAs observed an adequate supply of emergency water stored in this area. LPAs did not observed any obstructions and hazards during the visit.

Records review began at 11:28 am, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 1pm, six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Last emergency disaster drill was conducted in April of 2023. Executive Direcotr stated emergency disaster drill will be conducted before the end of the month.

Medications review began at approximately 1:00pm The medications are centrally stored in a med room on the fourth floor inaccessible to residents in care. Medication assistance is provided to nine (9) residents at this time. Medications are properly documented on the centrally stored medications and destruction record.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 02/08/2024

NARRATIVE

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Continued from 809-C

The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each resident bedroom as a single isolation rooms if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 11am - 03:00pm the LPAs interviewed six (6) staff members and six (6) residents.

LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2024 02:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 four (4) out of nine (9) bathrooms inspected the water temperature was measured above 120 degree F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2024
	Plan of Correction
1 2 3 4	During the inspection, the Maintance staff lowered the water temperature. Executive Director agreed to send LPA a temperature log for the next five (5) days and send the log to LPA via e-mail by EOD 02/13/2024.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2024 02:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 as an emergency disaster drill was last conducted in April of 2023, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	During the inspection the Executive Director stated they will condcut an emergency disaster drill by the end of the month. The Executive Director also agreed to send proof of disaster drill conducted to LPA via e-mail by 02/29/2024 EOD.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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