197609532-3-19-2024-31-AS-HRAI-D3HSC5-20240319134459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609532
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:45:42 PM

Document Has Been Signed on 03/19/2024 01:45 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:	IVY PARK AT WEST HILLS		FACILITY NUMBER:	197609532
ADMINISTRATOR:	DAVIS, DINA		FACILITY TYPE:	740
ADDRESS:	9012 TOPANGA CANYON ROAD		TELEPHONE:	(818) 701-9550
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	90	CENSUS: 59	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Dina Davis, Administrator		TIME COMPLETED:	02:10 PM

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At 9:00 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Business Office Director, Marilu Mampell, and later Administrator, Dina Davis, arrived and LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

The facility is a two-story building with resident rooms containing private bathrooms, multiple public bathrooms, five (5) staff offices, four (4) common areas upstairs, and two (2) downstairs, a dining room, kitchen, one (1) indoor activity space downstairs and one (1) upstairs, three (3) laundry rooms of which two are downstairs and one (1) is upstairs, outdoor space, and storage areas. The facility is divided into Assisted Living and Memory Care sections.

Kitchen: At 9:50 AM, LPA observed a clean and sanitary kitchen area. LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum one (1) week and perishable for two (2) days at the facility. Food was covered and all surfaces were clean.

Medications: LPA observed that the medication are kept in locked carts one upstairs and one downstairs. The carts would need access with an access code to open and access medications. Medications were inaccessible to residents in care.

Bedroom: LPA observed bedrooms which were clean, odorless, and free from debris. All furniture, walls, ceilings, and window screens were in good repair.

Bathroom: All public bathrooms and resident bathrooms were fully stocked with liquid soap, paper towels, trash cans with tight fitting lids, and handwashing instruction signs. Resident bathrooms also contained toilets and bathtubs with grab bars and non-skid surfaces. At 10:05 AM, hot water temperature measured at 117.4°F. The facility has a single boiler (water heater) at the facility.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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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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: IVY PARK AT WEST HILLS	FACILITY NUMBER: 197609532
	VISIT DATE: 03/19/2024

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Common Areas: The facility maintains a comfortable temperature at 74°F. There are four (4) common areas upstairs and two (2) downstairs and they all appeared clean and were properly furnished. LPA observed comfortable furniture. No obstructions and or tripping hazards throughout all the common areas of the facility.

Smoke detectors/carbon monoxide. LPA observed fire sprinklers, hard-wired smoke detectors, and carbon monoxide detectors in all bedrooms and throughout the facility.

Fire Extinguisher: LPA observed fire extinguishers in the dining room and in hallways with flashlights in cases. All fire extinguishers were fully charged and were checked on a quarterly basis. The most recent extinguisher inspection date was 3/04/24.

Memory Care Unit: The memory care unit used doors on all exits with 15 second delayed egress.

The Backyard/Outside: had a covered shaded area for residents with outdoor furniture. There is no body of water/swimming pool at the facility. The facility has two (2) emergency exit. Both emergency exits were unlocked. One of the emergency exit was to the parking lot of the facility without any lock. Emergency exit paths were free from debris.

Between 11:15 AM to 1:00 PM, LPA reviewed records of eight (8) residents and eight (8) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiencies cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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