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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:44:02 PM


Document Has Been Signed on 06/13/2024 02:44 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:CARRIES CARE VILLAFACILITY NUMBER:
197609782
ADMINISTRATOR:ACOSTA, MARK RYANFACILITY TYPE:
740
ADDRESS:12550 BURTON STTELEPHONE:
(818) 767-4503
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 5DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carrie AcostaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 11:14 a.m., the Licensee, Carrie Acosta arrived at the facility.

At 11:11 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:13 a.m., hot water measured at 105.2-degree Fahrenheit. Laundry units are located next to the kitchen in the laundry room.

BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident's use and one (1) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. During the tour, the LPA observed Resident #1 (R1), who is bedridden not residing in the bedridden room. The LPA held a conversation with the Licensee regarding the importance of following the facilities fire clearance.

RESTROOMS: The facility has two (2) bathrooms, one (1) for resident use and one (1) for staff use. Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:24 a.m., hot water measured at 105.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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Document Has Been Signed on 06/13/2024 02:44 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as in two (2) out of three (3) residents diagnosed with dementia need updated annual medical assessments which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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The Licensee stated that the medical assessments will be completed for the three (3) residents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 06/13/2024
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OUTDOOR SPACE: At 11:30 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. The property is gated. There are no bodies of water on the premises. There are two (2) locked sheds in the back patio that is used for storage. The garage is detached to the house and remains inaccessible to residents. The garage contains additional food and cleaning supplies.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 10/30/2023. At 12:00 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Medications are centrally stored and locked in a cabinet in the dining room area.

RECORD REVIEWS: Between 11:41 a.m. and 12:56 p.m., the LPA conducted a file review for all residents and staff regularly scheduled. Staff records were reviewed for documents including, but not limited to health screening, TB test, and fingerprint clearance. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Four (4) out of five (5) residents require updated appraisals/needs and service plan, technical violation issued. Two (2) out of three (3) residents diagnosed with dementia need annual medical assessments, citation issued.

Due to time constraints the LPA will return to complete the annual at a later date.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D). Civil penalty in the amount of $500 was assessed.

Exit interview conducted. A copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/13/2024 02:44 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as Resident #1 (R1) is bedridden and does not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The Licensee agreed to do the following:
1. Within 24 hours, the licensee will relocate the R1 to the room identified for bedridden residents only. Proof to be submitted to CCL by due date. This is a zero tolerance violation, resulting in a civil penalty in the amount of $500
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4