197608280-7-31-2024-29-AS-ECOZ-D6L2S2-20240625173825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 06/25/2024
Date Signed: 07/31/2024 10:27:42 AM

Document Has Been Signed on 07/31/2024 10:27 AM - 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:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 31	DATE:	06/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Clarizze Punit		TIME COMPLETED:	05:40 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 Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Administrator Clarizze Punit and explained the reason for the visit.

At 2:39 p.m. the LPA toured the physical plant areas inside and outside, with the administrator 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. At 2:41 p.m. the LPA observed a whole in the residents restroom door in room #101. At 2:45 p.m. the LPA observed two (2) clorox wipes bottles, one (1) Lysol can, one (1) Arnica Roll, (1) simply saline nasal mist bottle in room #103. At 3:00 p.m. the LPA observed one (1) Resolve Pet expert stain and color remover, one (1) container of Kaboom oxiclean, one (1) Miralax bottle, one (1) container of Tide Pods, one (1) container of fabric softener, one (1) bottle of prescribed Nystatin 100,000 unit/GM powder, and one (1) kitchen knife in room #105. At 3:22 p.m. the LPA observed a whole in the wall in room #226. At 3:28 p.m. the LPA observed one (1) bottle of Tide free and gente detergent, and dust and stains on the floor in room #228. At 3:30 p.m. the LPA observed one (1) bottle of Raid Ant &Roach, one (1) bottle of Pepto-Bismol, one (1) bottle of Lysol, and the drawer of the residents dresser falling, in room #227. All bedrooms that were observed were unlocked. The flooring was checked for cleanliness and carpet in bedrooms appeared stained in most bedrooms.

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. Restroom hot water were measured in resident restrooms between 112.6 and 116.4 degrees Fahrenheit between 02:44 p.m. and 3:20 p.m. Report will continue on LIC 809 - C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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 4

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: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/25/2024

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
26
27
28
29
30
31
32

KITCHEN: At 2:50 p.m. the LPA observed the kitchen/dining area. Knives are stored inaccessible to the residents in care. 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 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.

COMMON and OUTDOOR AREAS: At 3:34 p.m. the LPA observed stains throughout the carpet in the hallway on the second floor and a rip measuring at 5 feet. At 3: 36 p.m. the LPA observed a floor tile inside the elevator broken measuring at 14 inches by 10 inches. 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. he 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. Smoke detectors are hardwired and interconnected, at approximately 3:40 p.m. the smoke detectors were tested and operable. The LPA observed fire extinguishers fully charged and last serviced on 05/05/2024.

INTERVIEWS: The LPA conducted three (3) resident interviews. No immediate concerns were voiced during the visit.

Due to a time constraint, the LPA will return at a later date to complete the annual.

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 and copy of the report was ssued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 07/31/2024 10:27 AM - 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: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 ten (10) rooms observed as the they had disinfectants and cleaning solutions which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to do a full facility sweep and make sure any item that poses a danger to residents are removed, and will submit proof to CCL by 06/26/2024. Proof can be a self-certification letter or photos.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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 three (3) out of ten (10) resident bedrooms observed as they had over the counter and prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to do a full facility sweep and make sure that prescribed and over the counter medications are removed, and stored inaccessible to residents in care, and will submit proof to CCL by 06/26/2024. Proof can be a self-certification letter or photos.

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 07/31/2024 10:27 AM - 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: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 as the facility's carpet is in disrepair with stains and a 5 foot rip, there is a hole on a wall, hole on residents bathroom door, rooms need to be cleaned, and there is a broken tile inside the elevator which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2024
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: Ensure all listed items are fixed/cleaned by 07/08/2024. If carpet is being replaced please submit proof. Proof can be invoices, photos or self-certification letter.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4