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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:26:42 PM


Document Has Been Signed on 08/13/2024 02:26 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VILLAGE AT SHERMAN OAKS, THEFACILITY NUMBER:
197608694
ADMINISTRATOR:GRACE HARTNETTFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY:179CENSUS: 152DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Grace HarnettTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Trevor Byrne and Erica Mosley conducted an unannounced case management visit in regard to a self-reported incident that occurred on 08/06/2024. On that date Resident # 1 (R1) was administered the incorrect medication by Staff #1 (S1). S1 then informed the Enlivin Director (S2) of the error. R1 experienced a vomiting episode and was placed on monitoring by the resident’s physician.

Between 01:14pm – 02:30pm, LPAs conducted a brief physical plant tour, interviewed staff and reviewed pertinent documentation relevant to the incident.

Interviews conducted and records review revealed that community staff followed the appropriate reporting procedures and complied with the resident’s physician’s recommendations for monitoring. An in-service training was conducted on six (6) resident rights and avoiding medication errors. Three (3) staff including S2 attended the in-service. S1 at the time of the visit had terminated their employment with the facility.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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 08/13/2024 02:26 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2024
Section Cited
CCR
87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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Facility has conducted an in service training on 6 resident rights and avoiding medication errors. S2 attended and S1 has terminated their employment at the facility. POC cleared.
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(4) The licensee shall assist residents with self-administered medications as needed.
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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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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