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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 05/16/2022
Date Signed: 05/16/2022 12:59:02 PM


Document Has Been Signed on 05/16/2022 12:59 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: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: DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Melissa ChristopherTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Melissa Christopher and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Assistant Ulka Sanghavi to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms were observed to be single and double occupancy.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA reminded the Administrator to ensure that bathrooms displayed appropriate hand-washing signs. Restroom hot water measured between 114.0 and 119.8 degrees Fahrenheit between 10:29 a.m. and 10:46 a.m.



KITCHEN: At 10:09 a.m. the LPA observed the kitchen/dining area. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. The LPA was able to speak with chef to discuss menu choices. The facility has a pre-set menu however offers the option for residents to choose from a variety of different options if menu choices are not to their taste.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
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 7


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
VISIT DATE: 05/16/2022
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COMMON and OUTDOOR AREAS: At 10:05 a.m. the LPA observed the outdoor area. A small patio area is adjacent to the building and is accessible to residents. A shaded area with furniture is accessible to visitors and residents to visit. The common areas included a front lobby area, downstairs entertainment area and upstairs activity room. All areas were accessible for resident use with appropriate furnishings. The LPA observed cameras in all common spaces. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected. Fire alarm system and extinguishers were last serviced by the fire alarm company on 4/14/22. The LPA observed required postings on the hallway walls and reminded the administrator to ensure that the Department Provider Notices are displayed appropriately. Flooring was checked for cleanliness and appeared in good condition.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator Melissa Christopher regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The LPA also advised the Administrator to ensure staff continue wearing face masks at all times. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The Administrator advised the LPA that the elevator is still under repair and is currently waiting on a confirmed date of completion. The facility is expecting elevator inspections in upcoming weeks and will update licensing on the progress of the elevator repair. At this time the Administrator indicated that all the residents residing on the 2nd floor are able to access the 1st floor either unassisted or by escort.


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 via Email.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 05/16/2022 12:59 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 maintence staff was identified not be to asscoiated to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/16/2022
Plan of Correction
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The Adminsitrator agreed to the following:
1. Associate any staff that is wokring at the facility and submit proof to CCL.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 05/16/2022 12:59 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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 staff were observed to be wearing facemasks throughout the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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The Adminsitrator agreed to the following:
1. Enusre that staff are reminded immediatley on the use of masks while in the facility.
2. Review masking protocols with staff and notify CCL no later than 5/20/22.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7