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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608998
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:57:40 PM


Document Has Been Signed on 07/18/2024 03:57 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CANYON TRAILS AT TOPANGA SENIOR LIVINGFACILITY NUMBER:
197608998
ADMINISTRATOR:SUSAN WEISBARTHFACILITY TYPE:
740
ADDRESS:7945 TOPANGA CANYON BLVDTELEPHONE:
(818) 716-9900
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:120CENSUS: DATE:
07/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liliana Solorzano - Assisted Living DirectorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Perchui Milena Khurshudyan, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20240708170641. LPA met with the Assisted Living Director (ALD) Liliana Solorzano and explained the reason for the visit.
During the visit, LPA was informed that R1 was taken to West Hills Hospital on 06/15/2024, where it was determined that R1 had to be hospitalized. R1 stayed in the hospital from 6/15/24-6/19/24. On 6/22/2024 S1 noticed a skin tear on R1's leftforearm and reported to med-tech. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner for both incidents. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the ALD Solorzano admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the ALD that all staff members are mandated reporters and they are all responsible for reporting.
LPA informed ALD Solorzano to submit an incident report that occurred on:
• 06/15/2024
• 06/22/2024

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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 07/18/2024 03:57 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: CANYON TRAILS AT TOPANGA SENIOR LIVING
FACILITY NUMBER: 197608998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2024
Section Cited
CCR
87211(a)(1)(A)(B)(D)

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Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 06/15/24, and skin tear on left forearm on 6/22/24 which poses a potential health and safety risk to persons in care.
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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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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