197608663-9-5-2023-31-AS-TCAS-CVDSV7-20230905141216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608663
Report Date: 09/05/2023
Date Signed: 09/05/2023 02:12:34 PM

Document Has Been Signed on 09/05/2023 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CEDARCREEK MANOR		FACILITY NUMBER:	197608663
ADMINISTRATOR:	RICHARD K. GORDON		FACILITY TYPE:	740
ADDRESS:	27126 LANGSIDE AVENUE		TELEPHONE:	(818) 269-2230
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91351
CAPACITY:	6	CENSUS: 4	DATE:	09/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Elsie Gomez		TIME COMPLETED:	02:15 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) Tuesday Cabiness arrived at the facility to conduct an annual inspection. LPA was greeted by caregiver Elsie Gomez, who allowed LPA to enter. Administrator Dr. Richard Gordon was contacted, and everyone was informed the reason of the visit. A complete inspection/tour of the facility was conducted from the inside and outside. The following was observed during the inspection: Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer stocked with food, in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, and medication were stored in the kitchen and garage area which was locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (6) bedrooms; with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 116.6. degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. The facility has outdoor furniture, with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. All exit doors have alarms; all were operating. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly. Record review: A complete record review of staff and residents were conducted. Resident # 1 (R1) was missing a current appraisal needs/service plan. LPA observed Administrator Richard Gordon signed off on (2) physician reports, dated 01/05/2023 and 06/05/2022. LPA reviewed R1's records and determined that R1 has primary physician and is a Kaiser patient.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CEDARCREEK MANOR	FACILITY NUMBER: 197608663
	VISIT DATE: 09/05/2023

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Although the Administrator is a licensed medical professional, R1 has a primary physician and medical reports should be reviewed and signed by the appropriate doctor. Further review of this matter may need to be addressed at a later date and time. Technical violations issued to address the medical records and physician report. Medication records reviewed; no issues observed during visit. Staff records were reviewed.

Infection/Mitigation Control Review: Upon entry, staff checked LPA temperature and there was a sign in sheet with a cleaning station. The common areas were observed to be clean, including resident rooms, and staff and visitor bathrooms. Staff were not wearing masks upon entry but put them on during the inspection. Soap and towels, and hand washing signs were visually posted. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and throughout the facility. The facility has sufficient stock of PPE. The facility has cleaning procedures and protocols in place, which include staff cleaning common areas throughout the day. The facility has documentation of all vaccination records for staff and residents. There are current staffing issues; during today's visit, LPA observed (3) staff on duty.

The facility continues to implement the best practices for the facility; to ensure the health and safety of residents and staff. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC809 (FAS) - (06/04)

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