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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609496
Report Date: 08/27/2021
Date Signed: 08/27/2021 10:06:07 AM

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:ENCINO TERRACE SENIOR LIVINGFACILITY NUMBER:
197609496
ADMINISTRATOR:ARTEAGA, IRMAFACILITY TYPE:
740
ADDRESS:16025 VENTURA BLVDTELEPHONE:
(818) 986-8466
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:85CENSUS: DATE:
08/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Irina Konyavko/ Resident Service DirectorTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to an Incident report received in the Community Care Licensing (CCL) office on 8/17/2021. Upon arrival at the facility, staff took the LPA's temperature and documented the results.

The incident report received, indicated a fall that occurred on 8/1/2021. The resident (R1) in question, was inspected by the facility nurse and checked for any abrasions, bruises, or injuries. The facility had made internal documentation of the fall and since there was no reported injury, the facility did not deem the fall as an unusual incident and therefore did not submit an incident report. R1's responsible party and primary physician were notified of the fall. On 8/8/21, when R1 did mention that R1 was experiencing pain, an unusual incident report was submitted to CCL, timely.

At 8:15 am, the LPA spoke with the Resident Service Director, who is also a Licensed Nurse, and requested that all falls not only be documented at the facility, but an incident report be submitted to CCL as well.


No deficiencies cited during this visit. Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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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