197608650-5-15-2023-29-AS-AASO-CRUSUQ-20230515141130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608650
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:12:25 PM

Document Has Been Signed on 05/15/2023 02:12 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:	VISTAS - NORTH HOLLYWOOD		FACILITY NUMBER:	197608650
ADMINISTRATOR:	YANETT PEREZ		FACILITY TYPE:	775
ADDRESS:	10940 VICTORY BLVD., SUITE 103		TELEPHONE:	(818) 509-0150
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 45		CENSUS: 10	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Yanett Perez		TIME COMPLETED:	02:25 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 Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 10:35 a.m. The LPA met with Administrator Yanett Perez at 10:36 a.m. This Adult Day Program is vendor through the North Los Angeles County Regional Center (NLACRC). Entrance interview conducted. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. The facility consists of multiple rooms with activities for the clients to participate in. These rooms include kitchen/breakroom area, arts and craft area, volunteer/ community area, and a rest area. The rest area/ resting room will also be used as an isolation room in the event of COVID-19 exposure in the facility. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. There are two (2) total bathrooms at the day program. The toilets have grab bars. During the visit, the LPA observed signs in all of the bathrooms pertaining to proper hand hygiene. All cleaning supplies were inaccessible to client in care. In addition, both restroom hot water measured under 120.0 degree F. In all common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system is hardwired and operated normally at the time of visit. The fire alarm system and pull stations are tested annually by Absolute Fire Inc. The last inspection was dated 06/08/2022. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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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Document Has Been Signed on 05/15/2023 02:12 PM - It Cannot Be Edited

Created By: Angel Ascencio On 05/15/2023 at 01:38 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: VISTAS - NORTH HOLLYWOOD	FACILITY NUMBER: 197608650
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82068.2(d)(1)

Needs and Services Plan

(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old. 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 3 out of 5 reviewed client files did not have an updated IPP, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	Administrator will reach out to NLACRC to obtain current IPP. Administrator will send copies to CLL by 05/31/2023.

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:

Kristin Heffernan

LICENSING EVALUATOR NAME:

Angel Ascencio

LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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: VISTAS - NORTH HOLLYWOOD	FACILITY NUMBER: 197608650
	VISIT DATE: 05/15/2023

NARRATIVE

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No medications were observed a the day program. Administrator has policies and procedures in place if any future clients require medication management. There were no bodies of water noted.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed 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 facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control are adequate.

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.

- Starting at 11:30 a.m., during client file review, three (3) out of six (5) residents did not have their Needs and Service Plan or Individualized Program Plan (IPP) current within one (1) year.

Exit interview conducted and copy of the report and appeal right were issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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