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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:58:13 PM

Document Has Been Signed on 04/19/2022 01:58 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: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: 3DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH: Serguei KalistratovTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff and explained the reason for the visit. The Administrator Serguei Kalistratov arrived shortly thereafter.

The LPA, 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 LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are six bedrooms for resident use.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the visit, the LPA did not observe signage 2 out of 3 bathrooms pertaining to proper hand hygiene. In addition, restroom hot water measured between 115.8 and 138.2 degrees Fahrenheit between 10:32 a.m. and 10:42 a.m.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 13
Document is an Amendment of Original Document on 05/25/2022 04:55 PM


Created By: Elsie Campos On 04/19/2022 at 12:13 PM
Link to Parent Document Below:
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: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 2 out 3 restrooms measured water temperatures above 120 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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The administrator agreed to do the following:
1. Immediatley adjsut the water temperature on the water heater and notify CCL no later than 4/20/22.
2. Conduct a 5 day temperature check on all sinks and provide a log of measurements to CCL no later than 4/26/22.
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
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Based on observation, the licensee did not comply with the section cited above as cleaning supplies were accessible under the kitchen sink and unlcoked garage, which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Administrator agreed to do the following:
1. Immediatley secure all items. Plan of correction met at time of the visit.
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
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 04/19/2022 01:58 PM - It Cannot Be Edited


Created By: Elsie Campos On 04/19/2022 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on observation, the licensee did not comply with the section cited above as the LPA observed unlocked and accesible medications in multiple kitchen cabinets, which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Secure all medications with appropriate locking devices. Plan of correction met at the time of the visit.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 04/19/2022 01:58 PM - It Cannot Be Edited


Created By: Elsie Campos On 04/19/2022 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 the water heater door in the backyard was in disrepair and the kitchen diswasher was inoperable, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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The Administrator agreed to the following:
1. Repair or replace dishwasher and water heater door and submit proof to CCL no later than the POC date.
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
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Based on observation, the licensee did not comply with the section cited above as there were various expired pershiable items found which poses a potential health and safety risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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The Administrator agreed to do the following:
1. Dispose of any observed expired foods. Plan of correction met at the time of the visit.
2. Conduct an audit of all perishable and non-perishable foods and dispose of any expired items. Submit proof to CCL no later than POC 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
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
Page: 4 of 13
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: 04/19/2022
NARRATIVE
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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. All exits have functioning auditory devices. Smoke detectors are hardwired and interconnected and tested at 11:15 a.m. The fire extinguisher was observed to be full and last bought on 5/26/21. The LPA observed cameras in all common spaces and a screened fireplace in the living room. The LPA did not observe all the required postings in the common area. Amongst the missing postings were the department provider information notices (PIN) and department let me know poster. The administrator was reminded of the department’s guidelines regarding postings and signage. In addition, at 10:36 a.m., the LPA observed accessible personal hygiene, over the counter medications and prescription medications in the hallway closet, belonging to staff. These items were properly secured at the time of the visit.

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. At 10:57 a.m., the LPA observed the door to the water heater to be in disrepair, and advised the administrator to ensure it is repaired and secured.

KITCHEN: The LPA observed the Kitchen dishwasher to be inoperable, and per the administrator is not used. The administrator was advised that all kitchen appliances need to be in good repair and operable. The facility has a sufficient supply of perishable food and nonperishable food; however, the LPA observed expired hot dog buns, expired milk, and moldy cauliflower in the kitchen between 10:46 a.m. and 10:49 a.m. These items were disposed of at the time of observation. At 10:45 a.m., the LPA observed accessible cleaning supplies under the kitchen sink. At 10:33 a.m. the LPA observed unlocked medications in the clear medication cabinet. These items were properly secured at the time of the visit. At 10:44 a.m. the LPA observed unlocked kitchen knife cabinet, which was locked at the time of observation. At 10:52 a.m. the LPA observed an unlocked door leading to the garage and laundry area containing laundry detergent, disinfectants, and other chemicals. At 10:54 a.m. the LPA observed a kitchen cabinet with unsecured scissors which were properly secured at the time of the visit. Kitchen hot water measured 113.3 degrees Fahrenheit at 11:03 a.m.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 11 of 13
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: 04/19/2022
NARRATIVE
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INFECTION CONTROL: During today’s visit, the LPA 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. The LPA 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 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 does not have 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 administrator was also advised that all staff need to be cleared before entering the facility.

The following recommendations were made:
- Appropriate signage to remind staff and residents of hand washing hygiene, visitation policies and procedures etc.
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department. In addition to obtaining and displaying the departments Let Me Know poster.
-Continue Screening visitors and Staff and ensure visitors and staff continue following masking guidelines.


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 via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 04/19/2022 01:58 PM - It Cannot Be Edited


Created By: Elsie Campos On 04/19/2022 at 01:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WOODLAND HILLS RETIREMENT HOME
FACILITY NUMBER: 197609786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

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 in 1 staff at the facility is still pending clearance, which poses an immediate health and safety risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Administrator agreed to do the following:
1. Send staff home. Plan of correction met at time of the visit.
2. Staff needs to be cleared before working at the facility. Will advise CCL of clearance before staff's return to the facility.
Civil Penalties Issued
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Elsie Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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