197609049-10-6-2022-31-AS-NRED-CJXNV4-20221006104719

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 10/06/2022
Date Signed: 10/06/2022 10:47:29 AM

Document Has Been Signed on 10/06/2022 10:47 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FALLBROOK GLEN OF WEST HILLS		FACILITY NUMBER:	197609049
ADMINISTRATOR:	LILIT CHAPARYAN		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 95	DATE:	10/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	10:56 AM

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At 8:55 a.m. on 10/06/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 09/16/2022 for a complaint visit. It is a two story building with assisted living and memory care units. Shared and private rooms, common areas, offices, beauty salon, therapy room, medication room, and outdoor areas. It has an approved fire clearance for 114 nonambulatory residents, of which 8 may be bedridden. The facility serves residents with dementia. Approved hospice waivers for 15.

The facility’s masking policy was posted at the main entrance. LPA was screened for infectious disease upon entry. The screening station contained a mounted digital thermometer, hand sanitizer, and visitor log. The visitor log tracked contact tracing information, temperature, symptoms, and vaccination status.

Facility postings included the facility license, Ombudsman contact, confidential complaint contact, Emergency Disaster Plan, and theft policy. COVID precautions were posted throughout the facility. Sprinkler systems and fire alarms were located throughout the building. A fire inspection permit valid until 12/31/2022 was posted.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 9:10 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. The first floor contained office spaces, dining room, kitchen, laundry room, and private and shared rooms. Bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Some rooms had postings that a video camera was present inside. One room had a notice “No Smoking – Oxygen in use”. The second floor contained a therapy room, beauty salon, linen closets, and shared and private rooms.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FALLBROOK GLEN OF WEST HILLS	FACILITY NUMBER: 197609049
	VISIT DATE: 10/06/2022

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The memory care unit used 15 second delayed egress doors at all exits. Residents were observed in the dining room and outdoors in the back yard. Furniture was socially distanced and in good repair. An activity room contained workout equipment, books, and art supplies. Fire doors were suspended by magnets, and a sprinkler system spanned throughout the halls. The public bathroom near the main entrance contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid. At 9:43 a.m. LPA measured the water temperature to be within regulations.

All emergency exit paths were free from obstructions. Exit gates were unlocked. LPA observed fully charged fire extinguishers in the hallways. They were inspected on 09/08/2022. A patio area in the center of the facility had shaded areas with furniture in good repair. The dining room was adjacent to the patio area. The dining room contained socially distant furniture and was sanitary. All staff wore masks in the kitchen and laundry areas. The kitchen was clean and free of debris. The walk in freezer was broken, so the facility used two surplus freezers.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

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