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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609889
Report Date:
05/03/2022
Date Signed:
05/03/2022 02:44:45 PM
Document Has Been Signed on
05/03/2022 02:44 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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
PEARL OF WEST HILLS, INC
FACILITY NUMBER:
197609889
ADMINISTRATOR:
IRINA, KARBACHINSKIY
FACILITY TYPE:
740
ADDRESS:
23427 VICTORY BLVD
TELEPHONE:
(818) 854-6306
CITY:
WEST HILLS
STATE:
CA
ZIP CODE:
91307
CAPACITY:
6
CENSUS:
5
DATE:
05/03/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Irina Karbachinskiy
TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced required annual visit. LPA met with administrator and explained the reason for this visit.
Upon entry LPA was properly screened using covid protocols. LPA had temperature checked and signed into facility log.
LPA conducted a physical plant tour from 9:10-9:30am. Facility has four bedrooms and three bathrooms. Four bedrooms and two of the bathrooms are for resident use. One bathroom is designated for staff and visitors. LPA observed all resident bedrooms and bathrooms to be appropriately furnished. Carbon monoxide and smoke detector are combination and hard wired throughout the facility and were functioning properly.
LPA observed the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. Sharp objects were observed to be locked away and inaccessible. Medications are stored in a lock cabinet in the laundry area which is adjacent to the kitchen area. Common areas were observed to be properly furnished. LPA checked the backyard for clutter and debris. There is an additional non-attached dwelling unit on the property which is gated off from the facility. Administrator states she lives in the unit.
Facility has two residents that are receiving hospice services at this time. LPA observed one resident to have full bed rails but is not receiving hospice services.
Exit Interview conducted. Deficiency cited on LIC 809 D. Appeal Rights explained.
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/03/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/03/2022
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
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Document Has Been Signed on
05/03/2022 02:44 PM
- It Cannot Be Edited
Created By:
Wendell Smith
On
05/03/2022
at
11:31 AM
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., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
PEARL OF WEST HILLS, INC
FACILITY NUMBER:
197609889
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/03/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(5)(b)
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation it was observed that resident #4 had a full bed rail and is not on hospice. This is an immediate health and safety risk to residents in care.
POC Due Date:
05/06/2022
Plan of Correction
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4
Administrator shall have bed rail removed on R4's bed. Administrator will contact R4's physician regarding bed rail
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:
Cassandra Harris
LICENSING EVALUATOR NAME:
Wendell Smith
LICENSING EVALUATOR SIGNATURE:
DATE:
05/03/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/03/2022
LIC809
(FAS) - (06/04)
Page:
2
of
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