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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 06/19/2023
Date Signed: 06/19/2023 04:45:22 PM

Document Has Been Signed on 06/19/2023 04:45 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:CLARIZZE PUNITFACILITY TYPE:
740
ADDRESS:12120 CHANDLER BLVDTELEPHONE:
(818) 487-0770
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91607
CAPACITY: 49CENSUS: 39DATE:
06/19/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Ulka SawghaviTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Staff Ulka Sawghavi and explained the reason for the visit. This is an annual continuation that was first conducted on 05/16/2023.

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

Staff Files: At 10:30 a.m., LPA Ascencio reviewed five (5) staff files. Staff files were observed to be complete with the necessary documents.

Resident Files: At 11:20 a.m., LPA Ascencio reviewed five (5) resident files. At 11:22 a.m., Resident #1 (R1) and R2, review of file revealed a missing LIC 602, Physician's Report. R1 was missing their Tuberculosis results in their file.

Medication Audit: During medication audit review at 1:45 p.m., R3 had an empty bottle of Folic Acid 1mg and an empty bottle of Docusate Sodium 100 mg. LPA observed a routine medication order for both Folic Acid 1mg and Docusate Sodium 100 mg. Medications was not at facility during audit. Folic Acid 1mg has not been given since 03/11/2023 and Docusate Sodium 100 mg has not been given since 05/25/2023. Additionally, R1 and R4 did not have multiple PRN medication on file, such as Lorazepam 0.5mg, Robafen 5-10-100, , Seroquel 25 mg, Senna 8.6 mg, Loperamide 2mg, Milk of Magnesia, Tylenol 325 mg. Due to the facility not having their “as needed” medication at the facility, if R1 and R4 requested additional PRN medication, the facility would not be able to assist R1 and R4.

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 a copy of the report and appeal rights were issued to staff Ulka Sawghavi.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 3
Document Has Been Signed on 06/19/2023 04:45 PM - It Cannot Be Edited


Created By: Angel Ascencio On 06/19/2023 at 03:47 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply with the section cited above as R1, R3 and R4 did not have their medication on file which staff cannot assist with the self-administration of medication which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator stated they will submit a plan to conduct a medication audit. Addtionally, the facility pharmacy will be called to do their own audit. Laslty, facility will have pharmacy provide medication training. Administrator will submit documents to CCL by 06/21/23.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/19/2023 04:45 PM - It Cannot Be Edited


Created By: Angel Ascencio On 06/19/2023 at 03:47 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: FOUR SEASONS ASSISTED LIVING CENTER LLC
FACILITY NUMBER: 197608280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

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 R1 and R2 did not have their LIC 602 Physician's Report on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator will have the LIC 602 completed for R1 and R2 and submit to CCL by 06/30/23.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

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 R1 did not have their Tuberculosis results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Administrator will have R1 tested for Tuberbulosis and send results to CCL by 06/30/23.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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