197608357-11-28-2022-29-AS-ASMH-CLLT8Z-20221128133111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608357
Report Date: 11/28/2022
Date Signed: 11/28/2022 01:31:40 PM

Document Has Been Signed on 11/28/2022 01:31 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:	HILLTOP HAVEN #1		FACILITY NUMBER:	197608357
ADMINISTRATOR:	GLEN E. THOMAS		FACILITY TYPE:	740
ADDRESS:	20550 AETNA STREET		TELEPHONE:	(818) 474-9671
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 6	DATE:	11/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Tom Stiles		TIME COMPLETED:	01:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 11:25 a.m. The LPA met with staff and explained the reason for the visit. Facility Designee Tom Stiles arrived shortly thereafter, and the LPA explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals were locked inaccessible in the kitchen cabinets. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. At 11:45 a.m., the LPA observed alcohol accessible in the refrigerator. The items were disposed of upon observation.

BEDROOMS: Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear, and no obstructions were noted. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 12:15 p.m., water temperature measured at 105.5 F. Restrooms were fully stocked. Hand-washing signs were observed in all restrooms.

COMMON SPACES: There was a hallway closet with extra linens and towels. Fireplace in the living room was appropriately screened. Medications and files were locked and inaccessible. Fire extinguisher was fully charged and purchased 11/2022. The backyard had furniture and a covered area for resident use. The side gate was self-latching; no bodies of water noted. The facility does not have a garage on the property. The washer and dryer were in the kitchen. Detergent was locked and inaccessible.

FILES: The LPA reviewed resident files at 11:55 a.m. One (1) out of six (6) residents (Resident #1 – R1) required an updated appraisal. There were two (2) residents on hospice at the time of the visit. The facility had an appropriate hospice waiver on file. The LPA reviewed staff files at 12:20 p.m. Staff files were in order at the time of the visit. Contact information was confirmed during today's visit.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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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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: HILLTOP HAVEN #1	FACILITY NUMBER: 197608357
	VISIT DATE: 11/28/2022

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INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed throughout the facility. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility's procedures as it pertains to infection control are adequate.

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2022 01:31 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: HILLTOP HAVEN #1	FACILITY NUMBER: 197608357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 alcohol was observed accessible in the refrigerator, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/28/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Items were secured upon observation. Plan of Correction met.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/28/2022 01:31 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: HILLTOP HAVEN #1	FACILITY NUMBER: 197608357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [6] resident files (R1), which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/12/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. Update the appraisal for R1; submit completed appraisal to CCL no later than 12/12/2022.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

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