197609786-5-20-2021-29-AS-ARIN-C37L3L-20210520082406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 05/19/2021
Date Signed: 05/20/2021 08:27:12 AM

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:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	05/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Serguei Kalistratov, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Aja Richardson and Sandra Urena arrived at the facility unannounced to conduct a required annual visit 9:00 am. This annual had a specific emphasis on infection control practices and procedures. The LPAs met with Administrator and explained the reason for the visit.

The LPAs, with the guidance of staff, 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.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six bedrooms for resident use. At 9:am, the LPAs observed Room #2 and #5 there were accessible medications observed in the room.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPAs did not observe signage in any of the bathrooms pertaining to proper hand hygiene. In addition, at 9:45 am, the LPAs observed accessible cleaning supplies in the bathroom. This item was properly secured upon observation.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a temperature of 75 degrees. All exits have functioning auditory devices; however, at the time of the visit, they were turned off. The LPAs observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in 2 out of 5 rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2021
	Plan of Correction
1 2 3 4	Administrator locked up cleaning supplies during visit. Administrator will review regulation and train staff on regulation. Submit training topic, staff signiture, and date of training by POC due date.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 in 3 out of 5 rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Administrator locked up medications during visit. Administrator will review regulation and train staff on regulation. Submit training topic, staff signiture, and date of training by POC due date.

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2021
	Plan of Correction
1 2 3 4	Administrator agreed to buy additional emergency food and submit from receipts by POC due date.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
	VISIT DATE: 05/19/2021

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KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable food; however, the facility does not have a sufficient seven day supply of non-perishable food.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. However, based on observation, the LPAs observed that the facility did not utilize the central entry point and was not screening visitors. LPAs observed 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 not sufficient. Facility does not have sufficient disinfectants. 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 has not had a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following recommendations were made:
- Appropriate signage to remind staff and residents of cough etiquette, visitation policies and procedures, hand hygiene, etc.
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department
-Continue Screening visitors and Staff.

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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