197608523-10-25-2023-29-AS-SURA-CWXL5T-20231025082738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608523
Report Date: 10/24/2023
Date Signed: 10/25/2023 08:28:51 AM

Document Has Been Signed on 10/25/2023 08:28 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:	CALIFORNIA SENIOR OF SHERMAN OAKS		FACILITY NUMBER:	197608523
ADMINISTRATOR:	JEFFERSON REYES		FACILITY TYPE:	740
ADDRESS:	14802 MORRISON STREET		TELEPHONE:	(818) 849-5525
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY:	6	CENSUS: 5	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jefferson Reyes		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA met with staff Heber Alcazar and explained the reason for the visit. The Administrator Jefferson Reyes arrived shortly thereafter.

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

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two fire extinguishers were fully charged and were last purchased on 10/11/2023. The LPA observed required postings throughout the common space. Linen closet had sufficient linens for all residents.

KITCHEN: The kitchen area was observed to be clean. Knives and cleaning supplies are stored inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured within the required limits.

BEDROOMS: There are five bedrooms designated for residents' use. Bedrooms are private. Bedrooms were clean, properly furnished and had sufficient lighting. Appropriate bedding and linens were observed.

RESTROOMS: The three residents’ restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The staff’s restroom was clean and sanitary. The restrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured within the required limits.

Continues on LIC 809C...page 2.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CALIFORNIA SENIOR OF SHERMAN OAKS	FACILITY NUMBER: 197608523
	VISIT DATE: 10/24/2023

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OUTDOOR AREA: Entry/exits were free of obstruction. The outdoor area has furniture appropriate for outdoor use. The garage is a separate structure from the home and is used for storage/office. The laundry area is just off the kitchen, detergents are stored in a locked shelf in the laundry area. Washer and dryer appeared to be functional.

RECORDS: Records review began at 12:15 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:15p.m. Medications are centrally stored and locked in a kitchen cabinet; medications are labeled and were checked for expiration dates. During the medication review the LPA and the licensee observed that the medications were not properly documented on the centrally stored medications and destruction record. The following errors were observed during the medication review. Five (5) out five (5) residents’ Centrally Stored Medication and Destruction Record forms were incorrectly filled out. The forms had incorrect dates for when prescriptions were filled, prescriptions started, missing or incorrect quantity of pills. At least one medication (Escitalopram-5mg/90pills/date filled 2/11/2023) was not given to resident as prescribed by physician. The pill count in the medication bottle was 97 pills.

INFECTION CONTROL: 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 COVID-19.

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.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Deficiencies were cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/25/2023 08:28 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: CALIFORNIA SENIOR OF SHERMAN OAKS	FACILITY NUMBER: 197608523
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as one medication (Escitalopram) was not given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee will request training from a professional entity to provide medication training. Licensee will submit paperwork as proof to CCL/LPA indicating the training was completed.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 one bottle of medicine (Escitalopram) had 97 pills and the botlle indicated (90 count) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee will request training from a professional entity to provide medication training. Licensee will submit paperwork as proof to CCL/LPA indicating the training was completed.

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: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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