197608711-11-18-2023-31-AS-JGTN-CXPUWP-20231118145705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608711
Report Date: 11/18/2023
Date Signed: 11/18/2023 02:57:45 PM

Document Has Been Signed on 11/18/2023 02:57 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:	FOOTHILL RETIREMENT CARE HOME		FACILITY NUMBER:	197608711
ADMINISTRATOR:	JECERY NINONUEVO		FACILITY TYPE:	740
ADDRESS:	6720 SAINT ESTEBAN STREET		TELEPHONE:	(818) 353-3350
CITY:	TUJUNGA	STATE: CA	ZIP CODE:	91042
CAPACITY:	72	CENSUS: 33	DATE:	11/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Claudia Torres - Executive Director		TIME COMPLETED:	03:00 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) Gary Tan initially met with staff Brenda Jimenez for a One (1) Year Required visit for this facility. Staff Brenda called the Executive Director Claudia Torres and explained the reason for the visit. Ms. Torres arrived about 45 minutes later. A tour of the physical plant was conducted at 9:42 AM and the following was noted: There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance with hand washing sink. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan. There are hand sanitizing stations all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms and all over the common areas of the facility. The facility have designated visitors' area at the back yard. The facility has sufficient stock of PPE in the storage. The facility has three (3) separate buildings on the same property. First property is the main building consisting, of living room, dining room, kitchen and offices. Second building is called the Cottages which consists of six (6) individual units and the third building is the memory care unit (MCU) which has delayed egress installed on all exit doors, MCU consists of dining room, medication room and beauty shop. All indoor and outdoor passageways/exits were free of obstruction. There is no body of water in the facility. The facility maintains a comfortable temperature at 75°F. The facility is fire cleared for 72 non-ambulatory residents, 40 of which may be bedridden. Approved for delayed egress and hospice waiver for ten (10) residents.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

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: FOOTHILL RETIREMENT CARE HOME	FACILITY NUMBER: 197608711
	VISIT DATE: 11/18/2023

NARRATIVE

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(continued from LIC 9099)

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and properly stored at the facility. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible.
Bedrooms: The resident bedrooms were properly furnished with one chair, 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.
Bathrooms: LPA observed all bathrooms to be clean, properly supplied and equipped with functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. There are four (4) common shower rooms in the facility, all observed to be clean and in good repair. Hot water was measured in random bathroom at the range of 122.4°F to 142.3°F and observed to be outside of the required range.
Common Areas: These includes the living room, dining room and outdoor areas. Facility common areas appeared to be clean and appropriately furnished at the time of this visit, no accessible hazards were observed. Surrounding Grounds (Outdoors): The property has a covered patio area behind the main building with chairs and additional umbrella covered tables. There is also a covered picnic area in the back of the building. The facility's smoke alarms are hard wired and tested regularly every month. Fire inspection was last done on 08/18/23 and valid until 07/31/25. The facility is also equipped with sprinkler system which was last tested on 08/18/23 and valid until 07/31/25. Fire extinguishers are located all throughout the facility and were last serviced on 03/02/23 Fire drill was last conducted on 09/26/23.

Medications were observed to be stored in designated Medication room. The Medication room was observed to be locked at the time of visit. There is a complete set of first aid kit in the Medication room.
Resident/Staff File Review: LPA reviewed records of four (4) random residents and five (5) staff. Resident and staff records appeared to be complete and updated.
Laundry room located in a separate structure near the garage.

Citation issued. Appeal rights discussed and issued. Exit interview conducted. Copy of this report issued,

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/18/2023 02:57 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOOTHILL RETIREMENT CARE HOME	FACILITY NUMBER: 197608711
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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, random bedrooms and common shower rooms hot water was measured between 122.4°F to 142.3°F, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Administrator agreed to adjust the water by tomorrow, 11/19/23 and will submit a hot water temp log for each building for the next seven days and submit to CCL copy of the log.

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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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