197609827-9-5-2024-29-AS-EMOY-D8U4M9-20240905191310

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 09/05/2024
Date Signed: 09/05/2024 07:13:33 PM

Document Has Been Signed on 09/05/2024 07:13 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: 4	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	MERLE PACADA		TIME COMPLETED:	07:25 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 Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator was not available and designated staff / caregiver Merle Pacada to lead the tour and sign the report. The 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.
Documents obtained: LIC 500, LIC 9020A, Liability Insurance.

KITCHEN: The LPA inspected the kitchen/food service area at 10:15 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 119.7 degrees Fahrenheit at 10:18 a.m. Cleaning solutions, toxins, chemicals, and hazardous items were inaccessible and locked away inside a kitchen cabinet under the sink. At 10:39 a.m., the LPA observed five (5) cockroaches inside two kitchen cabinets posing a health and safety concern.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 2:35 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 8/14/2024. The LPAs observed required postings throughout the common space. The last emergency disaster drill took place on 08/04/2024. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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 6

Document Has Been Signed on 09/05/2024 07:13 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(h)(2)

Planned Activities

(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use. 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 one (1) out of (1) one shaded covering which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Get a covering for outside area.

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 as vermon was visible in kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Pest control will come and spray facility.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 09/05/2024 07:13 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 four (4) out of four (4) resident medications were presorted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2024
	Plan of Correction
1 2 3 4	Will send proof that meds are soretd on a daily basis.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 09/05/2024 07:13 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: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 one (1) resident is not in the correct room for bedridden which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Resident will be moved to the correct room.

Type A

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. 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 one (1) emergency exit gate/ self latching gate does not open / close properly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/10/2024
	Plan of Correction
1 2 3 4	Gate will be fixed and picture will be sent to LPA.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

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: 09/05/2024

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
26
27
28
29
30
31
32

Report Continued from LIC 809...
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. It was observed that a bedridden resident was not in the correct room cleared for bedridden. This was addressed and informed that it is an immediate health and safety risk resulting in civil penalty.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Between 10:55 a.m. and 11:30 a.m., hot water measured between 118.9 and 119.9- degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 12:00 p.m., the LPA observed the back of the facility and front patio area which is partially covered / shaded with trees for the outdoor area for resident use. Staff was made aware that area needs to be cleaned for resident use and proper covering is required.

There is a gate on the sides of the house designated for an emergency exit that needs repair. This was addressed and informed that it is an immediate health and safety risk resulting in civil penalty. One of the self-latching gates is not operating properly and does not open smoothly or close at the time of this visit. Staff and administrator was made aware that the gate needs to be fixed immediately. There are no bodies of water on the premises noted at the time of the visit. The garage is not accessible to residents. Laundry units are located outside at the back of the facility.

RECORDS: Records were reviewed from approximately 1:00 p.m.- 2:00 p.m. personnel records began at approximately 1:00p.m Resident Records were reviewed at approximately 1:45 p.m.Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued from LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 09/05/2024

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
26
27
28
29
30
31
32

Report Continued from LIC 809C...
Three (3) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. Four (4) resident interviews were attempted. Two (2) interviews were conducted.

MEDICATIONS: Medications review began at approximately 4:30 p.m. The medications are locked in a cabinet near kitchen between staff room and staff bathroom. Medications for four (4) out of four (4) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. Medications were pre-sorted for two days in advance. Staff was made aware that medication cannot be pre-sorted and made aware of the potential health and safety risk.

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. The Licensee was made aware that 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6