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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:07:37 PM

Document Has Been Signed on 04/30/2024 03:07 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEARL OF WEST HILLS, INCFACILITY NUMBER:
197609889
ADMINISTRATOR/
DIRECTOR:		IRINA, KARBACHINSKIYFACILITY TYPE:
740
ADDRESS:23427 VICTORY BLVDTELEPHONE:
(818) 854-6306
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 3DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Olga KnyazevaTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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At 12:35 p.m. on 04/30/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and staff contacted the administrator at approximately 1:00 p.m. and disclosed the reason for the visit. LPA and S1 toured the facility inside and out.

The facility was last visited on 03/22/2024 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06).

The front yard was well maintained and free of hazards. At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:50 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Puzzles, board games, and exercise equipment were observed in the living room. Surveillance cameras monitored common areas. Three (03) out of three (03) auditory alarms were tested and functioning. At approximately 12:55 p.m. two (02) out of four (04) smoke and carbon monoxide detectors were tested and operational. Two (02) smoke alarms were removed. S1 showed LPA two (02) new smoke alarms were purchased due to the old detectors malfunctioning.

The facility has three (03) bathrooms. One (01) bathroom is private, and two (02) are shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:58 p.m. and 1:03 p.m. LPA measured the water temperatures in the bathrooms near the main entrance to be 135.1 degrees Fahrenheit and 136.3 degrees Fahrenheit. This deficiency is addressed on the LIC 809-D page.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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 9
Document Has Been Signed on 04/30/2024 03:07 PM - It Cannot Be Edited


Created By: Nicholas Reed On 04/30/2024 at 02:16 PM
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: 04/30/2024

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
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Based on observation, the licensee did not comply with the section cited above in two (02) out of three (03) water faucets which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
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Licensee has agreed to lower the hot water temperature on the water heater and send proof of water temperature measured within regulations by POC due date.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 04/30/2024 03:07 PM - It Cannot Be Edited


Created By: Nicholas Reed On 04/30/2024 at 02:16 PM
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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (01) out of two (02) employees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee has agreed to provide proof of updated CPR certificate for Staff #1 (S1) and maintain in facility file by POC due date
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (01) out of two (02) employees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee has agreed to provide proof of TB Test for Staff #1 (S1) and maintain in facility file by POC 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/30/2024 03:07 PM - It Cannot Be Edited


Created By: Nicholas Reed On 04/30/2024 at 02:16 PM
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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (02) out of three (03) resident medical assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee has agreed to obtain current medical assessments for Resident #1 (R1) and Resident #2 (R2) and maintain in the faiclity file by the POC due date.
Type B
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of one (01) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee agreed to obtain a new or recently inspected fire extinguisher for the kitchen by the POC 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEARL OF WEST HILLS, INC
FACILITY NUMBER: 197609889
VISIT DATE: 04/30/2024
NARRATIVE
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The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All hospital beds had locked, secured wheels.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 04/20/2020. LPA discussed this deficiency with the administrator at approximately 2:00 p.m. The deficiency is cited on the LIC 809-D page. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were out of order. S1 stated the facility is seeking repairs for the machines and performing resident laundry at a local laundromat in the meantime.

LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. The wind had knocked down the large retractable umbrella. Ramps leading out were secure. The emergency exit path was free from obstructions. Exit gates were unlocked.

At approximately 1:45 p.m. LPA conducted a record review of resident and personnel files. S1’s tuberculosis test and updated CPR and First Aid certificates were not available for audit. Resident #1 (R1) and Resident #2 (R2) had diagnoses of dementia on their medical assessments. Their most recent medical assessments were older than 12 months. These deficiencies were cited on the LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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