197610151-7-27-2024-31-AS-JGTN-D7KTPJ-20240727145425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610151
Report Date: 07/27/2024
Date Signed: 07/27/2024 02:54:42 PM

Document Has Been Signed on 07/27/2024 02:54 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:	AEGIS LIVING GRANADA HILLS		FACILITY NUMBER:	197610151
ADMINISTRATOR:	MATTHEW LA VINE		FACILITY TYPE:	740
ADDRESS:	10801 LINDLEY AVE		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	100	CENSUS: 78	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Andrea Hernandez - Business Office Manager		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Gary Tan and Michael Cava arrived to this facility today to conduct a One (1) Year Required inspection of the facility. LPAs met with Business Office Manager Andrea Hernandez and explained the reason for the visit. The facility is fire cleared for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). Executive Director Lance Shenk called and designated Ms. Hernandez to sign the report. There is only one entrance being utilized at the facility, the front main entrance door. Screening area is located immediately upon entrance. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan. There are hand sanitizing stations all over the facility. There are signs of Covid 19 prevention protocol posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, and the other common areas of the facility. The facility have multiple designated visitors' area in the front entrance and backyard. The facility has sufficient stock of PPE in the storage room. LPA conducted physical plant tour of the facility with Ms. Hernandez, residents' bedrooms on the first, second and third floors were inspected. Common areas, including the activity rooms, movie theater, dining rooms and library appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen, dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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: AEGIS LIVING GRANADA HILLS	FACILITY NUMBER: 197610151
	VISIT DATE: 07/27/2024

NARRATIVE

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(continued from LIC 809)

There were no pesticides or poisons observed near any food areas. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 114.6°F to 118.7°F and within the required range.

LPAs observed fire extinguishers throughout the facility hallways on all three (3) floors, all extinguishers were last inspected on 06/06/24. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor. The facility's smoke alarms are hard wired as back up and tests are done in house on a monthly basis.

Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 07/10/24. A fire protection equipment performance certification was completed on 07/31/24.
In addition to the physical plant inspection, residents and staff records were reviewed.

LPAs reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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