197609827-9-26-2023-29-AS-EPEI-CW33JE-20230926181725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 09/26/2023
Date Signed: 09/26/2023 06:17:57 PM

Document Has Been Signed on 09/26/2023 06:17 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:	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:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Jeffrey Alvarez, Licensee		TIME COMPLETED:	06:30 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	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:37 a.m., the LPA met with staff and explained the reason for the visit. At 11:30 a.m., the Licensee arrived at the facility. At 10:30 a.m., the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:33 a.m., hot water measured at 105.4-degree Fahrenheit. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside a kitchen cabinet. At 10:35 a.m., the LPA observed three (3) cockroaches inside a kitchen cabinet. During the time of the visit, the Licensee began to remove all items inside the kitchen cabinet. The Licensee explained that the facility does receive pest control services and the next scheduled service is for September 28, 2023. BEDROOMS: The facility is a single-story residential home with seven (7) bedrooms, five (5) for resident use and two (2) for staff use. The facility has four (4) bathrooms, two (2) for resident use and two (2) for staff use. 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. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Between 10:43 a.m. and 10:56 a.m., hot water measured between 125.4 and 130.6-degree Fahrenheit. The Licensee was made aware of the water temperature and stated that he will adjust the temperature. The sinks had sufficient liquid soap, and paper towels. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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 09/26/2023 06:17 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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

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 between 125.3- 130.6 degrees) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Licensee agreed to adjust the water temperature by 9/27/2023 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 10/06/2023.

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as 2 of 5 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the centrally stored which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/27/2023
	Plan of Correction
1 2 3 4	Within 24 hours, the Licensee will notify LPA when training will be completed. Licensee agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by 10/06/2023.

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) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
	VISIT DATE: 09/26/2023

NARRATIVE

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OUTDOOR SPACE: At 10:48 a.m., the LPA observed the back of the facility and front patio which has a covered outdoor area for resident use. There are two gates on the sides of the house designated for an emergency exit. There are no bodies of water on the premises. The garage is not accessible to residents. Laundry units are located outside at the back of the facility. 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 07/12/2023. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. Exit has functioning auditory devices. At 2:45 p.m., fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked hallway closet.

Between 10:52 a.m. and 11:15 a.m., the LPA conducted interviews with three (3) staff and one (1) resident and attempted to interview an additional two (2) residents.

Between 12:41 p.m. and 1:48 p.m., the LPA conducted a review of medication and medication documentation with staff for five (5) residents and observed the following: Resident #1 (R1’s) Hydrochlorothiazide 12.5 MG tablet had 17 tablets remaining, however the medication was started on 09/12/2023 and the quantity was 30. Resident #2 (R2’s) Allopurinol 300 MG tablet had 16 tablets remaining, however the medication was started on 09/16/2023 and the quantity was 30.

RECORD REVIEWS: Between 1:50 p.m. and 3:28 p.m., the LPA conducted a file review for all residents and staff regularly schedule. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. The following was observed Staff have current first aid and required documents. However, one (1) staff file reviewed did not contain proof of health screening and negative tuberculosis test. Additionally, the annual training was completed for all staff, however the numbers are incorrect. The Licensee will correct and send the corrected training to the LPA. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Two (2) out of five (5) residents with dementia diagnosis did not have updated medical assessments.

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). The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report of provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/26/2023 06:17 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: VIP SENIOR LIVING LLC	FACILITY NUMBER: 197609827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as 2 residents files reviewed did not contain a current medical assessment and both residents have a dementia diagnosis, which poses a potential health and personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	Licensee stated that they will obtain current medical assessments for both residents and provide proof to CCL by POC due date.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 cockroaches were observed in the kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/09/2023
	Plan of Correction
1 2 3 4	The Licensee stated that the facility does receive pest control services and the next scheduled service is for September 28, 2023. The Licensee will send proof of corrections by 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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