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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607943
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:15:42 PM

Document Has Been Signed on 12/04/2024 03:15 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:VIRGINIA CATALINA LLCFACILITY NUMBER:
197607943
ADMINISTRATOR/
DIRECTOR:		KEVIN SCANLANFACILITY TYPE:
735
ADDRESS:7000 MORSE AVENUETELEPHONE:
(818) 394-9878
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 4DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Kevin ScanlanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:17 AM. LPA met with facility staff who contacted the facility Administrator Kevin Scanlan via telephone call. The Administrator arrived to the facility at 11:00 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 11:00 AM, the LPA, along with the Administrator 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:

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use. LPA observed the backyard to contain a fountain. The fountain was observed to be empty containing no water or other hazards to clients in care.

GARAGE: The garage was observed to be locked and inaccessible to clients in care. LPA observed the garage to contain an additional freezer, gardening supplies, cleaning supplies, and care supplies.

KITCHEN: The LPA observed the kitchen area to be clean. 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 a secured cabinet to contain knives and resident medications. The LPA observed a fire extinguisher to be fully charged and purchased on 06/04/2024. LPA observed the facility laundry adjacent to the kitchen. The laundry was observed to contain a washer and dryer as well as a properly secured cabinet containing detergents and other cleaning supplies.
Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 12/04/2024 03:15 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/04/2024 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIRGINIA CATALINA LLC
FACILITY NUMBER: 197607943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 one faucet was measured dispensing 125.8 degree water which poses a potential safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee will submit proof of appropriate water temperature to CCL no later than POC due date.
Type B
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 one employee file was observed to be missing a completed medical assessment and TB test which poses a potential health and safety risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee will submit proof of completed medical assessment and TB test 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 Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


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Document Has Been Signed on 12/04/2024 03:15 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/04/2024 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIRGINIA CATALINA LLC
FACILITY NUMBER: 197607943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(8)
(b) Each record must contain information including, but not limited to, the following:

(8) Medical assessment, including ambulatory status, as specified in Section 80069.

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 one client file was observed to be missing medical assessments which poses a potential health risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee will submit proof of completed medical assessments for the identified client to CCL no later than POC due date.
Type B
Section Cited
CCR
85070(a)(3)
(a) In addition to Section 80070, each client record must contain the following information:

(3) Needs and Services Plan and any modifications thereto, as specified in Sections 80068.2, 80068.3, 85068.2 and 85068.3.

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 one client file was observed to be missing an appraisal needs and services plan which poses/posed a potential health or personal rights risk to persons in care.
POC Due Date: 12/18/2024
Plan of Correction
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Licensee will submit a completed appraisal needs and services plan for the identified client 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 Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


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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: VIRGINIA CATALINA LLC
FACILITY NUMBER: 197607943
VISIT DATE: 12/04/2024
NARRATIVE
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Continued from LIC 809.

BATHROOMS: There are two (2) bathrooms at the facility. Both are designated as a common resident bathrooms. Both bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. All grab bars were observed to be in good repair and were properly secured. The water temperature was measured in both bathrooms between 105.8 degrees Fahrenheit and 125.8 degrees Fahrenheit which is outside of the appropriate range specified in regulation.

BEDROOMS: There are five (5) bedrooms in the facility; four (4) are designated for resident use and one (1) is designated as a staff room. All four (4) resident bedrooms are private rooms. LPA and the Administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The staff room was observed to be locked and inaccessible to clients in care.



COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain an appropriately screened fireplace, a table, chairs, and activities for resident use. The dining room was observed to be clean and contains an appropriately screened fireplace and adequate seating for resident use. The hallway was observed to contain one (1) set of cabinets and one (1) closet. The set of cabinets were observed to contain extra linens. The closet was observed to contain cleaning tools. Cameras were observed in the dining room and the living room. LPA confirmed with the Administrator that audio is not recorded. Smoke detectors and carbon monoxide detectors were tested at 11:18 AM and were functional at the time of the visit.

RECORD REVIEW: Record review began at 11:25 AM. 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, consent forms, and personal rights. Two (2) staff files were reviewed. One (1) staff file was observed to be missing a completed medical assessment and TB test. Four (4) resident files were reviewed. One (1) resident file was observed to be missing medical assessments and one (1) resident file was observed to be missing an appraisal needs and services plan.
Continued on LIC 809C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
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: VIRGINIA CATALINA LLC
FACILITY NUMBER: 197607943
VISIT DATE: 12/04/2024
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Continued from LIC 809C.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 12:23 PM. Medications are stored centrally and securely in a locked cabinet in the kitchen. Medications for three (3) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resource review was conducted for four (4) clients. All cash resources were accounted for and had the appropriate accompanying receipts. No deficiencies were observed during cash resource review.

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. The facility’s emergency disaster drills are conducted quarterly and the last emergency disaster drill was conducted 10/10/2024. The facility’s emergency disaster plan and infection control plan are reviewed/updated by the facility administrator annually.

INTERVIEWS: LPA interviewed one (1) staff member, the staff member interviewed was knowledgeable on their role, responsibilities, personal rights, the forms of abuse, ant the appropriate reporting procedures for suspected abuse. LPA interviewed one (1) resident. The resident interviewed had no concerns with the facility.



During today’s visit LPA obtained a copy of the facility’s updated LIC500, and liability insurance. The facility Administrator was unavailable to sign this report and has designated facility staff to sign on their behalf.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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