197609641-5-24-2023-29-AS-BBAI-CS5VBE-20230524161726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609641
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:18:28 PM

Document Has Been Signed on 05/24/2023 04:18 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, THE		FACILITY NUMBER:	197609641
ADMINISTRATOR:	HANNAH MEYERS		FACILITY TYPE:	740
ADDRESS:	21711 VENTURA BLVD		TELEPHONE:	(818) 999-2610
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 88	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jeanne Skondin		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 8:45am. Upon arrival LPAs met with Executive Director Jeanne Skondin and explained the reason for the visit. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. DINING ROOM / KITCHEN: The LPAs began the inspection in the kitchen/food service area at 9am Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At approximately 9:15am the LPAs observed non-perishable items in poor condition – Evaporated Filled Milk (expired 03/27/2023), Nacho Cheese sauce (expired 2/2023). Dining room furniture were observed to be in good condition and appeared to be relatively clean. LPAs observed (1) resident having breakfast in the dining room. COMMON AREAS: LPAs inspected the common areas throughout the facility. The common areas include the following on the first floor a library, multi-purpose / activity room, dining room, bistro, and the auditorium. On the second floor has the memory care area with patio, 2 sitting / living rooms. All the rooms have been appropriately furnished. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced March 2023

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
	VISIT DATE: 05/24/2023

NARRATIVE

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Continued from 809
All exits in Memory care have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces.

BEDROOMS: At approximately 9:20am, LPAs inspected (20) randomly selected bedrooms in memory care and assisted living. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels.

RECORDS: Records review began at 09:55 am, ten (10) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Records review revealed on 4/30/2023, Resident 1 (R1) was admitted into the facility and physician's report dated 04/28/2023, lists R1 as having no capacity for self-care which is a prohibited health condition. The licensee did not submit an exception request to admit and retain the resident with a prohibited health condition.

Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Out of the ten (10) files reviewed the Administrator's file was missing the following - Administration certificate, Education Verification, LIC 501, LIC 503, TB Test / Result, LIC 9052, SOC 341A . (5) out of (10) staff files reviewed do not have a valid first aid / CPR certification on file.

MEDICATIONS: Medications review began at approximately 01:23pm The medications are centrally stored in a med room on the third floor inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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: 05/24/2023

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Continued from 809-C

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of COVID. 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 facility’s policies and procedures as it pertains to infection control are adequate at this time.

Between 11am - 12:30pm the LPAs interviewed ten (10) staff members and ten (10) residents.

LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2023 04:18 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87615(a)

Prohibited Health Conditions

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as R1 was admitted to the facility as total care and an exception is not on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to submit a statment of understanding of regulation 87615(a) and obtain a new LIC 602 and submit to CCLD via email by COB 5/25/2023

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2023 04:18 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as (5) out of (10) staff files reviewed did not have a valid first aid / CPR certification on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	LIcensee agreed to have all staff files to be complaint with first aid and CPR notification and will submit proof of certification via email to CCL by COB 06/02/2023.

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above as the Administrator file is missing the following documents: Admin Cert, Education Verification, LIC 501, LIC 503, TB Test, LIC 9052, SOC 341a, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	LIcensee agreed to submit the required documents to CCL by 06/02/2023 via email by COB.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 05/24/2023 04:18 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: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above as LPA's observed multiple non-perishable items pass their expiration dates. which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	Licensee discared items at the time of visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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