197608478-10-2-2023-29-AS-BBAI-CW8UGV-20231002153457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608478
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:37:27 PM

Document Has Been Signed on 10/02/2023 03:37 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:	IVY PARK AT WOODLAND HILLS		FACILITY NUMBER:	197608478
ADMINISTRATOR:	PATRICE O'GRADY		FACILITY TYPE:	740
ADDRESS:	20461 VENTURA BLVD		TELEPHONE:	(818) 346-9046
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	127	CENSUS: 76	DATE:	10/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Patrice O'Grady - Executive Director		TIME COMPLETED:	04:00 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 Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:40am. Upon arrival LPAs met with Executive Director Patrice O'Grady and explained the reason for the visit. The LPAs 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. At 10:10am, a tour of the physical plant was conducted. Randomly selected residents' bedrooms on the first, second, third and fourth floors were inspected. Common areas, including the activity rooms, TV room, dining rooms, piano hall and sun room/library appeared clean and were properly furnished. DINING ROOMS / KITCHENS: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food in the kitchen properly stored. Residents do not have access to the kitchen, dangerous items are stored inaccessible to residents. The facility menu appears to meet the daily dietary needs for residents. There were no pesticides or poisons observed near any food areas. COMMON AREAS: LPAs inspected the common areas throughout the buildings. The common areas were observed to be properly furnished and relatively clean at the time of the visit. LPAs observed appropriate signage regarding infection control posted throughout the facility. LPAs observed sanitizer readily available in areas with high touch surfaces. Furniture was observed to be in good condition in each common area. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced October in 2022. The extinguishers are scheduled to be serviced by the end of this month. Last Emergency drill was conducted in September 2023 for a fire emergency and elopement emergency. The LPAs observed required postings throughout the common spaces.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 197608478
	VISIT DATE: 10/02/2023

NARRATIVE

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BEDROOMS: LPAs inspected twelve (12) randomly selected bedrooms throughout the four floors. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPAs observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.

There were storage room and storage areas located in the basement parking garage. Storage areas were observed to store emergency food supplies, extra medical supplies and medical equipment. At approx. 11:20am LPAs observed non-perishable items in poor condition - multiple canned goods pass their expiration date. Executive Director immediately discarded items. An advisory was provided. No obstructions or hazardous items to residents in care were observed in the parking garage at this time. A sufficient supply of PPE was observed in storage on the 4th floor.

Entry/exits were free of obstruction. The outdoor areas were clean and free of hazards. The patios and balconies have proper furnishings. The medications were observed locked in medication carts located on each floor.

RECORDS: Records review began at 11:30am, ten (10) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. Ten (10) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx. 11:45am , LPAs observed Resident #1 (R1) to have no capacity to self-care and is not on hospice.. Executive Director stated R1 has an updated LIC 602 in progress. An advisory was provided

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 197608478
	VISIT DATE: 10/02/2023

NARRATIVE

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Transportation vehicle records reviewed at approx. 11:30am - Pre-trip inspection conducted daily; service maintenance conducted every 5000 miles; insurance and registration checked; vehicles observed during visit. All files appeared to be in order at this time.

MEDICATIONS: Medications review began at approximately 12:30pm The medications are centrally stored and inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.

INFECTION CONTROL: Upon entry, there is a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene and symptoms of communicable diseases. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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 a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 01:00pm - 2:45pm the LPAs interviewed (8) staff members and seven (7) residents.

LPAs obtained the following documents - LIC 500, Census, Staff schedule, and updated Limited Liability insurance.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC809 (FAS) - (06/04)

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