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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610043
Report Date: 11/01/2024
Date Signed: 11/01/2024 01:50:26 PM

Document Has Been Signed on 11/01/2024 01:50 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:MEGAN'S PLACEFACILITY NUMBER:
197610043
ADMINISTRATOR/
DIRECTOR:		OSBORN, ANNIEFACILITY TYPE:
740
ADDRESS:7708 ETHEL AVENUETELEPHONE:
(818) 853-7654
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
11/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Annie OsborneTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:05 AM to conduct an unannounced Case Management visit at the facility today. LPA met with Administrator Annie Osborne. The LPA advised the Administrator of the reason for the visit.

During an investigation into a complaint at the facility, LPA Byrne interviewed the facility Administrator. Interviews with the Administrator revealed that Resident #1 (R1) was admitted to the hospital on 10/18/2024 or 10/19/2024 and again on 10/24/2024 and the Administrator did not submit an Unusual Incident/Injury Report (UIR) or written report to the Department. LPA informed the Administrator that a written report shall be submitted the Department within seven (7) days following an incident involving the facility’s residents. During file review it was also observed that R1 did not have a completed medical assessment signed by a physician prior to being accepted as a resident, a signed admission agreement, or a pre-placement appraisal. During the interview with the Administrator, they confirmed that they did not have did not have a medical assessment or signed admission agreement (resident admitted 10/15/2024) for the resident and had not conducted a pre-placement appraisal prior to accepting R1. LPA informed the Administrator that pre-admission appraisals and medical assessments signed by a physician are required for all residents prior to accepting them into their care.

During the physical plant tour LPA observed Resident #2’s (R2) bed to contain full bed rails. LPA reviewed R2’s file which revealed that R2 is not on hospice and does not have a physician’s order for full bed rails. LPA informed the Administrator who confirmed that R2 does not have an order for full bed rails. The Administrator removed the bed rails during the inspection.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 11/01/2024 01:50 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/01/2024 at 12:54 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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year....
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they have read the entirety of CCR 87458 and that they understand the importance of completing a medical assessment prior to accepting a client into their care no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as resident 1's file was observed to contain an incomplete medical assessment which poses a potential health and safety risk to clients in care.
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Type B
11/15/2024
Section Cited
CCR87457(a)(2)

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87457 Pre-Admission Appraisal General (a) Prior to admission, the... resident ...shall be interviewed by the licensee...
(2) The...resident's...her background, including...medical background... shall be discussed.
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they have read the entirety of CCR 87457 and that they understand the importance of completing a pre-admission appraisal prior to accepting a client into their care no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as no preadmission appraisal of resident 1 was completed prior to accepting resident 1 into care which poses a potential health and safety rick to clients in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 01:50 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/01/2024 at 01:07 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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a)... licensee shall furnish to the licensing agency such reports...
(1) A...report shall be submitted to the licensing agency...within seven days...
(D) Any incident...health of any resident...
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they have reviewed the entirety of CCR 87211 and that they understand the importance of accurate and timely reporting. Licensee will submit the statement to CCLD no later than POC due date.
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Based on record review and interview the licensee did not comply with the section cited above as no special incident reports were submitted for the hospitalization of Resident 1 which poses a potential health, safety, or personal rights risk to clients in care.
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Type B
11/04/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports
(a) ...Postural supports may be used under the following conditions. (5)...
(B) Bed rails that extend the entire length of the bed are prohibited except for ...hospice care...
This requirement is not met as evidenced by
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Licensee will remove the full bedrails from the identified resident's bed and will submit a statement of understanding that they have read CCR 87608 and understand the proper use of postural supports. licensee will submit proof no later than POC due date.
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Based on observation and record review the licensee did not comply with the section cited above as a resident's bed was observed to contail full bed rails, the resident is not on hospice and does not have a doctor's order for full bed rails which poses a potential personal rights risk to clients in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2024 01:50 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/01/2024 at 01:25 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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87507(c)

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87507 Admission Agreements
(c) Admission agreements shall be signed and dated...no later than seven days following admission...
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they have read the entirety of CCR 87507 and that they understand the importance of completing admission agreements in a timely manner. Licensee will submit documents to CCLD no later than POC due date.
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Based on interview and record review the licensee did not comply with the section cited above as a resident's file was observed to contain an admission agreement that was not filled out or signed which poses a potential personal rights risk to clients in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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