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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608927
Report Date: 12/13/2023
Date Signed: 12/14/2023 08:15:20 AM


Document Has Been Signed on 12/14/2023 08:15 AM - 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:JUST LIKE HOME IIFACILITY NUMBER:
197608927
ADMINISTRATOR:MARAT DAVIDIANFACILITY TYPE:
740
ADDRESS:13524 CHANDLER BLVD.TELEPHONE:
(818) 769-9955
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:6CENSUS: 5DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Alexsandra VartapetovaTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual visit. The LPA was greeted by staff, the LPA explained the reason for the visit. The facility representative Alexsandra Vartapetova arrived shortly thereafter.

LPA Urena, and the administrator conducted a tour of the inside, and outside of the facility to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

COMMON AREAS: The living room and dining room walls and flooring were checked for cleanliness and were observed to be in good condition. Furniture was observed to be clean, appropriate, and in good condition. Room temperature was recorded at 74 degrees Fahrenheit. A linen closet was observed by the entrance hallway. There were enough linens and towels for all residents. The LPA observed required postings by the main entrance hallway.

KITCHEN: The appliances were observed to be in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. An adequate supply of emergency food for six residents and two staff was available. Fire extinguisher was purchased on 08/25/2023. Kitchen knives were stored in the locked garage, and inaccessible to residents in care. The administrator was advised to fix the kitchen drawer to keep knives stored and locked within easy access to caregivers.

Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JUST LIKE HOME II
FACILITY NUMBER: 197608927
VISIT DATE: 12/13/2023
NARRATIVE
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BEDROOM: The facility has six bedrooms with single occupancy, each bedroom has a private bathroom. Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting.

BATHROOMS: Each of the six (6) bathrooms were observed to be clean; shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap, and paper products in each restroom. The facility has a staff/visitor bathroom in the hallway. Water temperatures in all bathrooms were recorded at temperatures within the regulations. OUTDOOR AREA/GARAGE: Backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. There were no bodies of water noted. Passageways were free of obstruction. Garage: Diapers, and Personal Protection Equipment (PPE) is adequate, and the facility is able to obtain additional supplies as needed. The supplies are found in the garage which is attached to the house. Door to the garage is kept locked and inaccessible to residents in care.

RECORDS: Records review was done between 1:15 p.m. and 2:40 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 3:05 p.m.; medications are centrally stored and locked in a closet located in the hallway and inaccessible to residents; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. The following errors were observed during the medication review. The Centrally Stored Medication and Destruction Record (LIC 622) was incorrectly filled out, and the medications Duloxetine and Amlodipine were missing from the LIC's 622 for two residents. Pursuant to Title 22 of the CA Code of Regulations, and the Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D).

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: LIC500 Personnel Report & LIC9020 Client Roster, and liability insurance certificate.

Deficiencies were cited at this time. Exit interview conducted. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/14/2023 08:15 AM - 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: JUST LIKE HOME II
FACILITY NUMBER: 197608927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as five out of five LIC622, were incorrectly filled out and had medications missing on the list of medications (Amlopidine and Duloxetine) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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The Administrator will contract a certified/qualified presenter to train staff on the procedures on how to fill the LIC 622 correctly and to ensure all meds are correctly included and listed in the LIC622. The administartor will email the LPA all documents pertaining to the training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/14/2023 08:15 AM - 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: JUST LIKE HOME II
FACILITY NUMBER: 197608927

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in one out of one resident's hospice information was not available for review at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/15/2023
Plan of Correction
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Administrator will email the LPA the Hospice Documentation along with (staff training) by Hospice agency on how to assist resident on reciving hospice services.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4