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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:06:35 PM


Document Has Been Signed on 09/27/2024 02:06 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: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: 32DATE:
09/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Administrator, Clarizze Punit TIME COMPLETED:
02:15 PM
NARRATIVE
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At approximately 9:55am Licensing Program Manager (LPM) KaSandra Lopez, and Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit due to a deficiency observed during complaint investigation of complaint control number 29-AS-20240920151349. The LPM and LPA advised the Administrator Clarizze Punit the reason for the inspection.

During the physical plant tour that started at 9:57am the LPA and LPM observed two (2) carts with cleaning supplies including Ajax with bleach, WD40, among other cleaning supplies on both carts that were unattended. It was also observed that the at 10:06 am the laundry room was unlocked with laundry detergent and bleach that were accessible to residents in care. Administrator was informed of the immediate health and safety hazard and was asked to ensure the door is locked at all times and that the carts were relocated to a locked location inaccessible to residents in care.

This citation is a repeat violation of the same deficiency cited on June 25, 2024. Therefore, civil penalties will be assessed.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or 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 issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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 09/27/2024 02:06 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
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: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
87309(a)

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87309 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 evidence by:
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Administrator secured the carts and locked the laundry room immediately during the visit. Administrator agrees to provide training to all staff regarding the regulation and submit proof by plan of correction date 10/11/2024.
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Based on observation the licensee did not comply with the section cited above in two carts with cleaning supplies were left unattended and the laundry room was unlocked with laundry detergent and bleach which poses an immediate health and safety risk to persons in care.
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica MosleyTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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