197609827-8-24-2021-29-AS-EPEI-C67VUC-20210824164431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 08/24/2021
Date Signed: 08/24/2021 04:46:48 PM

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:	VIP SENIOR LIVING LLC		FACILITY NUMBER:	197609827
ADMINISTRATOR:	AYLLON, MADELEINE		FACILITY TYPE:	740
ADDRESS:	5457 WOODMAN AVE		TELEPHONE:	(818) 994-4116
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	08/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jeffrey Alvarez		TIME COMPLETED:	04:55 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	At 2:00 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, Merle Pacada. This annual had a specific emphasis on infection control practices and procedures. At 3:00 p.m. Licensee, Jeffrey Alvarez arrived at the facility. Between 2:05 p.m. – 3:00 p.m., LPA 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. KITCHEN: At 2:15 p.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:16 p.m., LPA observed a baby gate at one entrance into the kitchen. Medications and first aid kits are kept in a locked cabinet in the hallway next to the staff room. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 2:08 p.m., LPA observed disinfectants in resident restroom. The staff removed these items upon observation. At 2:54 p.m., hot water measured at 129.0-Degree Fahrenheit. Licensee agreed to adjust the water temperature by 8/24/2021 and will maintain water temperature between 105- and 120-degrees Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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 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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2021

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
1 2 3 4	Based on observation, the licensee failed to ensure the hot water temperature was within the required range (tested at 129.0 degrees) which poses an immediate health and safety risk to residents in care.
	POC Due Date: 08/24/2021
	Plan of Correction
1 2 3 4	Licensee agreed to adjust the water temperature by 8/24/2021 and will maintain water temperature between 105- and 120-degrees Fahrenheit. The Licensee shall submit proof of a 5 day water temperature log indicating the hot water is within the required range of 105-120 degrees F to CCLD by 8/30/2021.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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, as there were disinfectants accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/24/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. The items were removed upon observation. Plan of Correction met.

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 Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

Page: 2 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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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, as a baby gate blocks access for the residents to enter the kitchen, which poses a potential personal rights risk to residents in care.
	POC Due Date: 08/25/2021
	Plan of Correction
1 2 3 4	Licensee agreed to remove the baby gate in the kitchen. Submit proof of completion by 08/25/2021.

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: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
	VISIT DATE: 08/24/2021

NARRATIVE

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Continued from LIC 809.

Common Areas: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and last serviced on 07/06/2021.

OUTDOOR SPACE: At 2:30 p.m., LPA observed the patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 3:00 p.m. - 4:00 p.m., LPA conducted Infection Control mitigation module with Licensee.

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. Report issued and a copy of the report and appeal rights was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC809 (FAS) - (06/04)

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