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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 04/15/2022
Date Signed: 04/15/2022 03:52:43 PM


Document Has Been Signed on 04/15/2022 03:52 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:FOUR SEASONS ASSISTED LIVING CENTER LLCFACILITY NUMBER:
197608280
ADMINISTRATOR:MELISSA CHRISTOPHERFACILITY TYPE:
740
ADDRESS:12120 CHANDLER BLVDTELEPHONE:
(818) 487-0770
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91607
CAPACITY:49CENSUS: 31DATE:
04/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Melissa ChristopherTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20220114163908.

During the investigation, the LPA conducted interviews and determined that staff have administered insulin injections to resident.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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 04/15/2022 03:52 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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87629(a) Injections. The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by:
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Based on interviews, the licensee did not comply with the section cited above, as staff have administered insulin injections to residents, which poses an immediate health and safety risk to residents in care.
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2. Administrator is going to conduct an in-service with staff regarding the administration of medications. Submit confirmation that all staff have been retrained to CCL no later than 4/29/2022.


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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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