197608982-2-11-2022-29-AS-ECAS-CBK2P3-20220211163340

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608982
Report Date: 02/11/2022
Date Signed: 02/11/2022 04:37:45 PM

Document Has Been Signed on 02/11/2022 04:37 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:	WALNUT GARDEN VALLEY VILLAGE		FACILITY NUMBER:	197608982
ADMINISTRATOR:	BUDNERO, MAIA DR		FACILITY TYPE:	740
ADDRESS:	12823 COLLINS STREET		TELEPHONE:	(818) 358-2033
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	02/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Izhak Illouz		TIME COMPLETED:	04:45 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’s) Elsie Campos and Ashley Smith arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA's met with Staff at 1:15 p.m. and explained the reason for the visit. Administrator Izhak Illouz arrived at the facility shortly thereafter. The LPA’s toured the physical plant areas inside and outside, with Administrator Izhak Illouz and assistant Arlene Ceballos at 1:30 p.m., to ensure there are no health and safety hazards. BEDROOMS: There are (6) six bedrooms designated for resident use and (1) one bedroom designated for staff use. Bedroom #3 and Bedroom #4 have a direct exit to the exterior. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Accessible cleanser and over-the-counter topical medication was observed in Bedroom #6. Oxygen was observed in Bedroom #2, yet the LPA’s did not observe the appropriate ‘No Smoking – Oxygen in Use’ sign. At the time of observation staff room was unlocked. The LPA’s observed prescription medication accessible inside the staff room. The LPA's advised staff to keep medication and other personal care items for staff locked and inaccessible. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA's observed sufficient amounts of soap and paper products. The LPA’s did not observe signs in the bathroom attached to bedroom #2 promoting good hand hygiene. The LPA’s advised the Administrator to ensure that bathrooms displayed appropriate hand-washing signs. Restroom hot water measured between 110.7 and 115.6 degrees Fahrenheit between 2:48 p.m. and 2:51 p.m. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, medications and chemicals were locked and inaccessible.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

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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Document Has Been Signed on 02/11/2022 04:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 as medications were accesible in the staff room which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/12/2022
	Plan of Correction
1 2 3 4	The administrator agreed to the following: 1. Secure all accesible medications and inform CCL when this has taken place but no later than 2/12/22.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 as over the counter ointment, cleaning supplies, toxic chemicals, laundry supplies were accesible in the detached garage which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/12/2022
	Plan of Correction
1 2 3 4	The administrator agreed to the following: 1. Secure all accesible items and inform CCL when this has taken place but no later than 2/12/22.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

Page: 2 of 13

Document Has Been Signed on 02/11/2022 04:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 as in 3 out of 6 residents (R1, R3, R5) have full bedrails but are not on hospice which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 02/18/2022
	Plan of Correction
1 2 3 4	The administrator agreed to the following: 1. Submit an exception request for R1, R3 and R5 to retain full bed rails. Submit to CCL no later than 2/18/22.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

Page: 3 of 13

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: WALNUT GARDEN VALLEY VILLAGE	FACILITY NUMBER: 197608982
	VISIT DATE: 02/11/2022

NARRATIVE

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FILES: During today’s visit, the LPA’s observed ½ bed rails for Resident #2, Resident #4, and Resident #6 (R2, R4, R6). Full bed rails were observed on the beds of Resident #1, Resident #3, and Resident #5 (R1, R3, R5). The Administrator confirmed that there were no residents receiving hospice care services at the time of the visit. The Administrator provided bed-rail orders for all six residents. However, the Administrator stated that they would submit exception requests for R1, R3, and R5 to have full bed-rails.

COMMON SPACES: The common spaces included the living room and dining area. The LPA's observed cameras in all common spaces and a screened fireplace in the living room. All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected, there is a Carbon Monoxide detector installed at the facility. The fire extinguisher was observed to be full and last bought on 12/1/21. The LPA's observed required postings on the wall leading to the kitchen. At 1:30 p.m. the LPA’s observed Lysol spray and disinfecting wipes accessible. Flooring was checked for cleanliness and appeared in good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage is detached from the house. At the time of the visit the garage was open. Upon observation LPA’s saw accessible laundry supplies, disinfectant, toxic pesticide spray and cleaning supplies.

INFECTION CONTROL: During today’s visit, the LPA's spoke with the Administrator Izhak Illouz regarding the facility’s infection control practices. The Administrator was advised that they need to ensure that visitors upon entry are signing in at a central entry point for symptom screening, temperature checks, and sanitation. The facility has a sufficient amount of Personal Protective Equipment (PPE). 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 facility does not have a confirmed case of COVID-19 at this time and the LPA's reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via Email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC809 (FAS) - (06/04)

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