197609641-5-31-2024-29-AS-VCOY-D5STUC-20240531150206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609641
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:02:18 PM

Document Has Been Signed on 05/31/2024 03:02 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMMONS AT WOODLAND HILLS, THE		FACILITY NUMBER:	197609641
ADMINISTRATOR:	KEVAN SIDNEY		FACILITY TYPE:	740
ADDRESS:	21711 VENTURA BLVD		TELEPHONE:	(818) 999-2610
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY:	200	CENSUS: 102	DATE:	05/31/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kevan Sidney		TIME COMPLETED:	03:30 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) Valeria Conway and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:40 am. Upon arrival LPAs met with Executive Director Kevan Sidney and explained the reason for the visit. At 9:49, 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 10:05 am 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. Dining room furniture were observed to be in good condition and appeared to be relatively clean. Facility has an adequate amount of non-perishable food, and emergency food and water. 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 is the memory care area with patio, 2 sitting/living rooms. All the rooms have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the of the visit. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The facility maintained a comfortable temperature. Smoke detector(s), carbon monoxide detectors and sprinkler system were operational at the time of the visit and last serviced, and clearance granted by fire marshal on 05/09/2024. Fire extinguishers were observed throughout the facility, fully charged and were last serviced March 2024. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Facility has four stairwells, LPAs observed each stairwell with an evacuation chair.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMMONS AT WOODLAND HILLS, THE	FACILITY NUMBER: 197609641
	VISIT DATE: 05/31/2024

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
26
27
28
29
30
31
32

Continued from 809

BEDROOMS: At approximately 10:15 am, LPAs inspected nine (9) 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. 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 11:12 am, seven (7) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records reviewed were complying at the time of the visit.

MEDICATIONS: Medications review began at approximately 12:10 pm 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.

Between 12:45 pm and 1:52 pm, LPAs interviewed seven (7) staff members and seven (7) residents. No concerns at the time of the visit.

LPAs obtained the following documents: Census, Staff schedule, Emergency Disaster plan, Fire Extinguisher, carbon monoxide, and sprinkler test records and updated Limited Liability insurance. Last disaster drill was conducted this month.

No deficiencies cited. Exit interview conducted and report issued to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2