197610043-5-18-2021-29-AS-KDUK-C35V88-20210518161218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610043
Report Date: 05/18/2021
Date Signed: 05/18/2021 04:14:33 PM

Document Has Been Signed on 05/18/2021 04:14 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MEGAN'S PLACE		FACILITY NUMBER:	197610043
ADMINISTRATOR:	OSBORN, ANNIE		FACILITY TYPE:	740
ADDRESS:	7708 ETHEL AVENUE		TELEPHONE:	(818) 853-7654
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 5	DATE:	05/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Annie Osborn		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Kelly Dulek and Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:45AM. This annual had a specific emphasis on infection control practices and procedures. The LPAs initially met with facility staff/designee Vergouhy (Virginia) Nazarian and discussed the reason for the visit. Administrator Annie Osborn arrived at 12:26PM.

The LPAs, along with facility designee Virginia Nazarian, 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.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 4 (four) total bedrooms; 3 (three) are for resident use and 1 (one) is designated as a staff room. During today’s visit, LPAs observed Resident #1 (R1) using Resident #2 (R2) and Resident #3 (R3)’s bedroom as a passageway to the backyard.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage was observed locked and contained the laundry area, as well as emergency food supply, and storage. The side gate is not currently self-closing/latching, and although it was not locked during today’s visit, the LPAs observed a padlock by the door. The Administrator was reminded that the side gate cannot be locked and the lock was removed during the visit. LPAs observed the ramp exiting the back sliding door has a broken threshold, creating a trip/fall hazard. The ramp leading outside from bedroom #3, Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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 05/18/2021 04:14 PM - It Cannot Be Edited

Created By: Kelly Dulek On 05/18/2021 at 02:51 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEGAN'S PLACE	FACILITY NUMBER: 197610043
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. 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 3 out of 3 total staff were not wearing masks when LPAs arrived at the facility which poses an immediate health risk to persons in care.
	POC Due Date: 05/18/2021
	Plan of Correction
1 2 3 4	During the visit, all staff put on surgical masks for the duration of the visit. Licensee will ensure staff are wearing masks at all times while working in the facility and in all common areas.

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

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. 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 due to damage to the ramp exiting bedroom #3, the broken threshold at the bottom of the back patio door ramp, and the non-self-closing gate which poses an immediate safety risk to persons in care, as both the bedroom ramp and the back door ramp are emergency exits.
	POC Due Date: 05/20/2021
	Plan of Correction
1 2 3 4	During today's visit, the licensee spoke with a maintenance person who will be fixing the ramps either on 5/19 or 5/20/2021. Licensee will sent photos to CCL as proof of work completed by 5/20/2021. Photographs of the gate closure shall be submitted to CCL by 5/25/2021. All work will be completed and photographs of completed work will be submitted by 6/1/2021.

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

LICENSING EVALUATOR NAME:

Kelly Dulek

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEGAN'S PLACE	FACILITY NUMBER: 197610043
	VISIT DATE: 05/18/2021

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which is designated for non-ambulatory and bedridden use, was observed to have severe damage, with broken pieces and exposed nails.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, however the facility is not currently allowing visitors. Additionally, LPAs observed 3 (three) staff all working in common areas and not wearing face coverings. Staff did put on masks during the visit. The LPAs observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed resident case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:
- Visitors should be allowed, per the guidance in Provider Information Notice (PIN) 21-17-ASC
- Face coverings should be worn by residents in common areas of the facility. All staff should wear a face covering while working in the facility and in all facility common areas.
- Post PINs and educate staff, residents, and families on changing policies and procedures from the Department

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. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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