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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609641
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:27:19 PM


Document Has Been Signed on 12/21/2021 04:27 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:COMMONS AT WOODLAND HILLS, THEFACILITY NUMBER:
197609641
ADMINISTRATOR:SOPHIA LUKASFACILITY TYPE:
740
ADDRESS:21711 VENTURA BLVDTELEPHONE:
(818) 999-2610
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: 104DATE:
12/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:47 PM
MET WITH:Hannah MyersTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #31-AS-20200131143649). LPA Camara met with
Executive Director Hannah Myers. The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation.

During the complaint investigation of complaint #31-AS-20200131143649, the following deficiencies were noted:

R1’s Needs and Services Plan, dated 12/16/2018, was not updated to reflect R1’s change of condition and assessment for possible higher level of care due to frequent falls and diagnosis of dementia. The admission agreement states: “Change of Service Plan and Level of Care – at a minimum the staff at the Commons will perform a semi-annual re-assessment of your needs, or a more frequent assessment if your condition warrants”. R1 was discharged from Topanga Terrace Skilled Nursing Facility (SNF) and admitted to the assisted living portion of the facility on 12/18/2018. The SNF discharge paperwork dated 12/18/2018 included a diagnosis of dementia without behavioral disturbance. The facility mini mental exam, dated 12/11/2018, stated “moderate cognitive impairment”. The assisted living resident assessment dated 12/11/2018 included “dementia” as a diagnosis and listed the level of care as a “5”. The SNF discharge paperwork, dated 05/30/2019, included a diagnosis of dementia without behavioral disturbance.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641
VISIT DATE: 12/21/2021
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On 04/16/2019, R1 was hospitalized due to a fall sustained at the facility. At the hospital, R1 was diagnosed with a urinary tract infection and pneumonia, along with a fracture of neck of right femur. This was added to diagnoses of osteoporosis and dementia. The fracture was categorized as pathological in nature, given R1’s osteoporosis. R1 was discharged from the hospital on 04/29/2019 to Topanga Terrace SNF for rehabilitation and discharged back to the facility on 05/30/2019. On 12/26/2019, R1 was found crawling on the floor by a caregiver during the overnight shift. The caregiver did not observe any injuries. R1 was sent to the hospital for evaluation and returned to the facility without injury at 5:00 a.m. on 12/26/2019. The Licensee did not submit a Special Incident Report for R1’s 04/16/2019 fall and hospitalization or R1’s 12/26/2019 unusual incident.

Citations issued, exit interview, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 12/21/2021 04:27 PM - 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: COMMONS AT WOODLAND HILLS, THE
FACILITY NUMBER: 197609641

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/24/2021
Section Cited

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87463(a) Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition….
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This requirement was not met as evidenced by:

Based on documentation review, R1’s Needs and Services Plan was not updated to reflect change of condition, which posed an immediate health and safety risk to residents in care.
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Type B
12/24/2021
Section Cited

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87211(a)(B) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require… (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
This requirement was not met as evidenced by:
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Licensee failed to submit a special incident report for R1’s 04/16/2019 fall and hospitalization and 12/26/2019 unusual incident, which posed a potential health and safety risk to residents in care.
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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: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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