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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610099
Report Date: 12/04/2024
Date Signed: 12/04/2024 02:40:40 PM

Document Has Been Signed on 12/04/2024 02:40 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:WYNGATE VILLA GARDENSFACILITY NUMBER:
197610099
ADMINISTRATOR/
DIRECTOR:
CHAVEZ, OSCARFACILITY TYPE:
740
ADDRESS:7634 WYNGATE STREETTELEPHONE:
(818) 352-4270
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 68CENSUS: 54DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Alma Espinal - Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required One (1) year visit at this facility today. LPA initially met with staff Vanessa Rodriguez who called the administrator and explained the reason for the visit. The Assistant Administrator Alma Espinal arrived thirty (30) minutes later.

A tour of the physical plant was conducted at 9:35 AM and the following was noted:

The facility consists of five (5) buildings, each house has one main entrance. There are required posters posted at each main door and all over the facility. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. All the staff were observed to be wearing mask. The facility had an approved Mitigation Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has multiple screening stations all through out the facility. The facility has sufficient stock of PPE in the storage room.

The facility has five (5) buildings with a total of (34) shared bedrooms. Each building has their own bathrooms ranging from one (1) at building #3 up to five (5) on building #2. The facility is fire cleared for forty six (46) ambulatory and twenty two (22) non-ambulatory residents, ten (10) of which maybe bedridden in building #2 only. Approved hospice for ten (10) residents. Common areas were inspected. All buildings has its own living room. Activity room is located on building #4 and dining area is located on building #2. Dining area was observed to be neat, clean and in proper order. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 04/04/24. The facility is equipped with emergency pull alarm and sprinkler system. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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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: WYNGATE VILLA GARDENS
FACILITY NUMBER: 197610099
VISIT DATE: 12/04/2024
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(continued from LIC 809)

Laundry room is located adjacent to the kitchen and was observed to be locked. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry room inaccessible to the residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature at building # 1 measured at 118.9°F, building #2 at 126.5°F, building #3 at 113.9°F, building #4 at 130.5°F and building #5 at 119.5°F. There were enough clean linen available in the closets.

Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room.

Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 10/18/24. A fire alarm inspection by the LAFD was last performed on 09/23/24 with validity until 03/31/27. There is no body of water in the facility. Back and front yard passageways were observed to be clear from obstruction. There is a shaded area on each building for the residents.

In addition to the physical plant inspection, residents and staff records were reviewed, LPA reviewed files of five (5) randomly selected residents. Residents files appear to be complete and updated. Six (6) staff files were also reviewed, staff files appear to be complete and updated.

Citation issued. Appeal rights discussed and given. Exit interview conducted. A copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2024 02:40 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 12/04/2024 at 12:52 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: WYNGATE VILLA GARDENS

FACILITY NUMBER: 197610099

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/04/2024

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 as the hot water temperature on Bldg #2 and Bldg #4 exceed the range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2024
Plan of Correction
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The Assistant administrator immediately called their maintenance person and will adjust the hot water temp on Bldg #2 & 4. The assistant administrator agreed to send a hot water log for the said bldg for the next seven (7) days (AM/PM) and will submit to CCL on or before the POC 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:Troy Agard
LICENSING EVALUATOR NAME:Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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