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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609065
Report Date: 07/21/2023
Date Signed: 07/24/2023 07:43:44 AM


Document Has Been Signed on 07/24/2023 07:43 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:NEST 2, THEFACILITY NUMBER:
197609065
ADMINISTRATOR:WEISMAN, MICHELLEFACILITY TYPE:
740
ADDRESS:15460 MORRISON STREETTELEPHONE:
(747) 998-5151
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:6CENSUS: 6DATE:
07/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Michelle WeismanTIME COMPLETED:
02:55 PM
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On 07/21/2022, at 10:00 a.m. Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena was greeted by staff and explained the reason for the visit. Administrator was not present at the facility, staff communicated via phone with Administrator Michelle Weisman to inform them of today’s visit. Administrator arrived at the facility short after.

At 10:30 a.m., LPA Urena and administrator conducted a tour inside and outside of the facility to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

Common Areas: LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area, and dining room furniture was observed to be in good condition. Fire extinguisher was observed to be purchased within the last year.

Bedrooms: LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens appeared to be clean and in good condition.

Bathrooms: LPA Urena observed the residents’ bathrooms. Paper towels were available for drying hands. There are communal shower areas, which were observed to be clean. Hand washing signs were displayed in each bathroom, and sufficient amounts of soap, and paper products in each bathroom.

Kitchen: LPA Urena observed the kitchen area. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods.

Outdoor Space: LPA Urena observed the outdoor space. The area has a shade for residents to sit outdoors, and furniture for residents’ use. There were no bodies of water noted.


Continues on LIC 809C...
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEST 2, THE
FACILITY NUMBER: 197609065
VISIT DATE: 07/21/2023
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RECORDS: Residents’ records review began at 12:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. The Appraisal/Needs and Services Plans were missing in six out of six residents’ files. The administrator stated that they will be emailed to the department by 07/28/2023. Personnel records review began at 12:20 p.m., records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Documentation of the required training for staff were missing in four out of four staff’s files. The administrator stated that all training was conducted via on-line. The administrator will send copies of the certificates of completion of the training for each of the four staff working at the facility by 07/28/2023.

MEDICATIONS: Medications review began at 12:45 p.m.; medications are centrally stored and locked in a storage room located in the dining room area; medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record (LIC 622). The LPA and staff observed that the medication bottles were observed to have a different Start dates compared to the LIC 622’s. The LPA audited two medications for two residents. The LPA and staff observed during the medication audit that the number of pills did not coincide with the Start date in the bottle. The administrator and the staff stated that the residents were admitted to the facility and residents had with them; consequently the medications were used because the pharmacy stated that they would not fill a new prescription and facility needed to use the medication that was left with the resident. The staff stated that they were not aware that they needed to create a new LIC 622 every time they received new medication.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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 LPA obtained the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
Deficiencies were cited during this visit. Exit interview was conducted. Signatures were obtained, and a copy of the report and deficiencies page was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/24/2023 07:43 AM - 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: NEST 2, THE

FACILITY NUMBER: 197609065

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of two bottles of medication Temazepam, Escitalopram, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Administrator will hire a professional to provide the required training to staff and will send a certificate of completion to the department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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