197608941-10-10-2022-29-AS-ECAS-CK3Q29-20221010114646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608941
Report Date: 10/10/2022
Date Signed: 10/10/2022 11:48:23 AM

Document Has Been Signed on 10/10/2022 11:48 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	NATURAL LIFE ASSISTED LIVING		FACILITY NUMBER:	197608941
ADMINISTRATOR:	TANNER, SHANNON		FACILITY TYPE:	740
ADDRESS:	5933 KENTLAND AVENUE		TELEPHONE:	(818) 346-3491
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 1	DATE:	10/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Shannon Tanner-Administrator		TIME COMPLETED:	11:55 AM

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) Elsie Campos arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Licensee Shannon Tanner and explained the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible, Licensee was reminded that all chemicals should remain locked at all times. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Two out of three rooms are for resident use; one bedroom is a staff room. Bedrooms had appropriate furnishings, clean linens, and sufficient lighting. A locked gun safe belonging to the Licensee was observed in bedroom #1. RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces. Licensee was reminded to ensure floors are cleaned regularly. At 11:15 a.m., water temperature measured at 116.1 F. The LPA observed hand hygiene signs in all restrooms. COMMON SPACES: Living room and dining furniture were observed to be in good condition. Exits have functioning auditory devices. Fire extinguishers were last purchased on 9/8/19. The Licensee was reminded that fire extinguishers must be replaced or serviced yearly. Required postings were observed throughout the facility. The backyard and exterior area of the facility had furniture and a covered area for resident use. There were no bodies of water noted at the time of the visit. A locked shed was observed in the backyard containing personal supplies and equipment.

INFECTION CONTROL: There is a central entry point for universal screening and temperature checks. The Licensee was reminded to ensure that temperature checks are continued to be conducted along with wearing appropriate face masks. There is a centralized location with COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available for use throughout the facility. There is an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

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: NATURAL LIFE ASSISTED LIVING	FACILITY NUMBER: 197608941
	VISIT DATE: 10/10/2022

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
26
27
28
29
30
31
32

This facility has records of staff vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines around visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate.

No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022

LIC809 (FAS) - (06/04)

Page: 2 of 6