197609049-9-3-2021-31-AS-APAA-C6HUKU-20210903153944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609049
Report Date: 09/03/2021
Date Signed: 09/03/2021 03:40:34 PM

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:	DANA ANDERSON		FACILITY TYPE:	740
ADDRESS:	6833 FALLBROOK AVE		TELEPHONE:	(818) 883-4123
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	114	CENSUS: 90	DATE:	09/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lily Chaparyan, Administrator		TIME COMPLETED:	04:00 PM

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At 12:00 pm Licensing Program Analysts (LPAs) Angela Panushkina, Joscelyn Martinez and Licensing Program Manager (LPM) Nichelle Gillyard conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by staff who granted access to the facility. LPA team met with Administrator Lily Chaparyan and a physical tour was conducted at 12:35pm and observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 05/11/2021) to make sure licensee was following current infection control recommendations. Upon arrival, staff took LPAs temperatures and was asked to sign-in the visitors’ log and were asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPAs advised the administrator to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. Team observed some trash can throughout the facility to not have fitted lids. Team requested that lids be placed on all trash cans to protect from cross from contamination.

Food Inspection: Team observed there to be sufficient supply of two perishable foods however one week of non-perishable food supply was borderline. The Administrator has agreed to purchase addition food and submit a copy of receipt by September 9^th, 2021. Food storage and preparation areas are clean and inaccessible to pests.

Smoke detectors/carbon monoxide are hard wire and tested yearly by the local Fire Department. LPA requested a copy of the report.

Resident rooms: All residents bedrooms were properly furnished, had sufficient lighting and appeared to be clean and had appropriate bedding.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

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: 09/03/2021

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At 12:20 the team inspected the memory care unit. The egress systems and staff response time was tested. The egress system was found to be operational. LPM discussed the importance of timely response by staff.

Bathrooms: The hot water temperature measured within regulation. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat.

Laundry service: At approximately 1:11pm, LPA team toured through the laundry area and observed cleaning products/chemicals inaccessible to residents.

LPA discussed the importance of maintaining the care and supervision to meet the needs of residents

Medications are centrally stored and locked.
Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents
There are no bodies of water.

LPA requested documentation to change the Administrator to be submitted to LPA. LPA left a copy of Provider Information Notice (PIN 21-40-ASC), “Updated Statewide Visitation Waiver, and Testing and Vaccination Verification Guidance for Visitors Related to Coronavirus Disease 2019 (COVID-19).
No deficiencies issued.

Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021

LIC809 (FAS) - (06/04)

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