197610121-2-11-2023-31-AS-NRED-CNY26G-20230211160708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610121
Report Date: 02/11/2023
Date Signed: 02/11/2023 04:07:37 PM

Document Has Been Signed on 02/11/2023 04:07 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WEST HILLS ASSISTED LIVING		FACILITY NUMBER:	197610121
ADMINISTRATOR:	MILLAN, JONATHAN		FACILITY TYPE:	740
ADDRESS:	7055 SHOUP AVENUE		TELEPHONE:	(818) 883-7201
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	90	CENSUS: 53	DATE:	02/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Chris Salvador		TIME COMPLETED:	04:00 PM

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At 9:30 a.m. on 02/11/2023, Licensing Program Analysts (LPA) Nicholas Reed and Gary Tan conducted an unannounced annual visit. LPAs met with staff and later Administrator designee and disclosed the reason for the visit. LPAs and Administrator designee toured the facility inside and out. No immediate health or safety protocols were observed.

The facility was last visited on 02/08/2023 for a complaint visit. It is a two story building with private and shared bedrooms, private and public bathrooms, common areas, activity rooms, dining room, laundry area, and outdoor areas. It has an approved fire clearance for 30 ambulatory residents and 60 nonambulatory residents, of which 15 may be bedridden. The facility serves residents with dementia. Approved hospice waivers for 30 residents.

Upon entry, LPAs observed signs for COVID precautions and the facility’s visitation policy. Once inside, additional postings included Emergency Disaster Plan, Ombudsman contacts, confidential complaint contacts, theft and loss policy, house rules, resident rights, and nondiscrimination policy.

LPAs were screened for infectious disease upon entry. The screening station contained a wall-mounted digital thermometer, hand sanitizer stations, gloves, surgical masks, and a visitor log. The visitor log tracked contact tracing information and temperatures.

LPAs conducted a record review at approximately 10:00 a.m. Recent fire tests and drills were reviewed, along with staff and resident records. The lobby area was clean and contained appropriate seating. LPAs observed residents in the television room near the main entrance. The television room contained furniture in good repair, a piano, and a television. The outdoor area was accessible from the television room. The outdoor area contained patio furniture in good repair and was shaded by umbrellas. At approximately 11:35 a.m. LPAs observed a fully charged fire extinguisher near the lobby. It was last serviced on 10/25/2022.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

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

FACILITY NAME: WEST HILLS ASSISTED LIVING	FACILITY NUMBER: 197610121
	VISIT DATE: 02/11/2023

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The medication room was locked and inaccessible to persons in care. Narcotics, medications, and resident files were locked. LPAs observed more resident files and PPE in a locked storage closet near the medication room. Public restrooms were clean and fully stocked with liquid soap, automatic dispenser, paper towels, handwashing instruction signs, and trash cans with tight fitting lids. Emergency devices were observed in the stairwell. LPAs toured resident bedroom from 11:55 a.m. to 12:30 p.m. Bedrooms were sanitary and free of hazards. Bathrooms and showers contained sturdy grab bars and non-skid strips. At 11:55 a.m., 12:00 p.m., and 12:10 p.m., water temperatures from resident bathrooms were measured at 116.4, 107.5, and 106.7 degrees Fahrenheit. Resident rooms contained chairs, nightstands, lamps, call systems, and beds with furnishings in good condition. LPAs observed an adequate supply of perishable and non-perishable foods in the kitchen. A daily menu and an alternate menu were posted. Emergency water and food supplies were observed. Sharps and cleaning solutions were locked and stored separately from food supplies. The walk-in freezer was 28 degrees Fahrenheit. The activity room contained exercise equipment, a chess board, puzzles, a bookshelf with reading material, art supplies, and a vending machine. The laundry room was located behind the activity room. It contained 4 operable machines. Detergents inside were locked and inaccessible. A janitorial closet and linen closet were also locked. The linen closet contained an adequate supply of fresh linens. An additional laundry area was located upstairs for residents to use. Fire sprinklers, alarms, and extinguishers were located throughout the facility. LPAs also observed a designated smoking area upstairs with appropriate signage, air filters, and plants. At 12:32 p.m. LPA Reed tested the carbon monoxide detector to be operational.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2023

LIC809 (FAS) - (06/04)

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