197608694-3-29-2022-29-AS-BBAI-CCYVVM-20220329164634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:47:11 PM

Document Has Been Signed on 03/29/2022 04:47 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:	VILLAGE AT SHERMAN OAKS, THE		FACILITY NUMBER:	197608694
ADMINISTRATOR:	PAMELA MUNDAY		FACILITY TYPE:	740
ADDRESS:	5450 VESPER AVE		TELEPHONE:	(818) 994-7900
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY:	100	CENSUS: 61	DATE:	03/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sahar Mosalla Operations Specialist		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 Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met Sahar Mosalla Operations Specialist and Mariana Pelayo Regional Nurse and explained the reason for the visit. The building has several floors divided into two separate areas. The "A" side of the building has three floors, of which the first and second floors are licensed to serve Assisted Living residents. The Independent living residences starts on the "B" side of the building starting on the "A" side third floor and continuing on the "B" side building with second, third and forth floor(s) (fl). The "B" side of the building is not under CCL authority. There is a shared elevator for both the "A" and "B" sides building. Bedrooms: At approximately 1:05pm, LPA inspected (13) randomly selected bedrooms. 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.LPA observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 107.4 - 115.7 degrees Fahrenheit. Common Areas: Between 1pm - 3:30pm, LPA inspected the common areas throughout the facility. These included dining areas, activity rooms, (2) libraries, sitting area, theater, fitness areas, cafe and patio. The common areas were observed to be properly furnished and relatively clean at this time. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed signs to wipe down each appliance after each use and sanitizer readily available in areas with self serve dispensers and coffee and snack stations.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: VILLAGE AT SHERMAN OAKS, THE	FACILITY NUMBER: 197608694
	VISIT DATE: 03/29/2022

NARRATIVE

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Continued from 809
Kitchen: The kitchen was observed to be only accessible to staff. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. LPA observed emergency food supply to be sufficient at this time. Dining furniture in dining room area appeared to be clean and sufficient at this time.
Memory Care: LPA inspected (3) randomly chosen rooms during physical plant. The resident bedrooms were observed to be 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. Each bedroom had a private bathroom. LPA observed each bathroom to be clean, properly supplied and had functional fixtures. LPA observed all resident bathrooms to have grab bars, non-slip material in showers and locked cabinets. The hot water was measured between 107 - 109 degrees Fahrenheit. There was an enclosed outdoor courtyard for memory care residents to use. There was an exit door that led into the parking lot. LPA observed an alarm sound off upon opening the exit door.

Outdoor Area: There were shaded areas throughout the exterior of the facility with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There is a pool located on the facility located on the independent living side of the faciltiy and designated for only independent living residents use at this time. LPA observed a gate to the pool to be closed and locked at this time. Parking Garage was accessible from the exterior. PPE and other cleaning supplies were located in a storage closet on the far wall near the exit of the garage. LPA observed storage to be securely locked and stored sufficient supply of PPE at this time.
The LPA spoke with Sahar and Mariana regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 any bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly for un-vaccinated and un-boosted staff. If anyone is showing symptoms they are tested right away with PCR rapid testing. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
Exit interview conducted. Report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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