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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 03/24/2022
Date Signed: 03/28/2022 11:57:48 AM


Document Has Been Signed on 03/28/2022 11:57 AM - 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:WOODLAND HILLS RETIREMENT HOMEFACILITY NUMBER:
197609786
ADMINISTRATOR:KALISTRATOV, SERGUEIFACILITY TYPE:
740
ADDRESS:24301 OXNARD STTELEPHONE:
(818) 564-4381
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 5DATE:
03/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Serguei KalistrotovTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Case Management – Deficiencies visit on 03/24/2022, in conjunction with complaint control # 29-AS-20200522094856. LPA met with facility administrator Serguei Kalistratov and explained the reason for the visit.

During the course of the investigation of the above noted complaint, it was discovered the administrator failed to do the following:

-obtain a hospice care plan for Resident #1 (R1) or retain any hospice records

-report R1 entering into hospice to Community Care Licensing (CCL)

-complete a reappraisal for R1 after R1’s hospital stays and change in condition

-report two incidents when R1 was admitted to the hospital.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued to administrator at serguei35@yahoo.com
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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 3


Document Has Been Signed on 03/28/2022 11:57 AM - 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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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87632 Hospice Care Waiver
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:
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(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of
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admission to the facility and the name and address of the hospice. This requirement was not met as evidenced by: No record of licensee reporting R1's entry into hospice to CCL was found, which posed a potential health and safety risk to residents.
Type B
04/01/2022
Section Cited

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87633 Hospice Care of Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plan approved by the licensee, the hospice agency, and the resident, or the
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resident’s Health Care Surrogate Decision Maker if the resident is incapacitated.
This requirement was not met as evidenced by: Licensee had no records regarding R1's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital health and safety risk to residents.
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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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/28/2022 11:57 AM - 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: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the
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events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as
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psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee failed to report two incidents of R1 requiring hospitalization, which posed a potential health and safety risk to residents.
Type B
04/01/2022
Section Cited

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87463 Reappraisals
(a) 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: After R1's two inpatient hospitalizations in which hospice was advised due to R1's declining health, licensee failed to complete a reappraisal of R1's condition, which posed a potential health and safety risk to residents.
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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: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3