197609856-11-22-2024-31-AS-LNCA-DB9QZP-20241122113703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609856
Report Date: 11/18/2024
Date Signed: 11/22/2024 11:37:09 AM

Document Has Been Signed on 11/22/2024 11:37 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WESTFIELD SENIOR LIVING		FACILITY NUMBER:	197609856
ADMINISTRATOR/ DIRECTOR:	BALASANYAN, MARIAM		FACILITY TYPE:	740
ADDRESS:	7633 MASON AVE		TELEPHONE:	(818) 384-1134
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	11/18/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:25 PM
MET WITH:	Armine Kiseleva- Designee		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Nadia Shahbazian met with facility designee Armine Kiseleva for a Plan Of Correction (POC) visit.

The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 10.23.2024

Entrance interview conducted.

At 12:45PM LPAs toured the home and requested the following:

-CCR 874659(c)(3) Incidental Medical and Dental Care Services:

POC: Based on record review, the licensee did not comply with the section cited above in 1 count out of 1 PRN medications were not documents in CSMDR which poses/posed a potential health, safety.

POC date 10.8.2024: All supplements and PRN medications is documented in CSMDR.

For todays visit 11.18.2024, LPAs saw a repeat violation that was cleared on 10.23.2024. Therefore, an immediate civil penalty is issued for failure to correct the violation, and a new LIC 809-D is created with a new Plan of correction (POC) date. Administrator was contacted and LPA was informed that all required documents will be submitted promptly.

Exit interview conducted, appeal rights given and a copy of this report signed and delivered.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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 11/22/2024 11:37 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WESTFIELD SENIOR LIVING	FACILITY NUMBER: 197609856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.This requirement
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee needs to ensure any hazardous items should be lock and inaccessible to residents.

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.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/22/2024 11:37 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WESTFIELD SENIOR LIVING	FACILITY NUMBER: 197609856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Licensee needs to ensure that R4 bedroom is free of other individuals belongings, only R4 can have their belongings inside.

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.

Nichelle Gillyard	TELEPHONE: (818) 596-4370
Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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