197610165-7-30-2024-31-AS-MAGN-D7NLE6-20240730084058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610165
Report Date: 07/29/2024
Date Signed: 07/30/2024 08:43:29 AM

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MCNULTY VILLA		FACILITY NUMBER:	197610165
ADMINISTRATOR:	WOOD, CHERIE		FACILITY TYPE:	740
ADDRESS:	20724 MCNULTY PL.		TELEPHONE:	(818) 395-6037
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 4	DATE:	07/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tresita Miller- Staff		TIME COMPLETED:	05:00 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 Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. LPA was informed that Administrator Cherie Wood could not attend the annual due to traveling. LPA contacted the Licensee to attend the annual inspection. LPA was informed that the facility doesn't have an administrator designee. At approximately 10:00 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the living room. The fire extinguisher is charged and located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA observed clutter on the breakfast table and a bottle of insect killer on the floor. LPA found an insufficient amount of perishable and non-perishable food at the facility; sharp objects were stored in an unlocked drawer in the kitchen. LPA observed a bottle of a cleaning solution under the kitchen sink unlocked. LPA observed flies in the kitchen and the kitchen fridge was unclean with spoiled fruits, vegetables, and leftover food. The laundry area is located through the kitchen. LPA observed that all laundry detergents were unlocked. Bedrooms: The facility has five (5) bedrooms. Four (4) bedrooms are designated for residents' use and one (1) bedroom is designated for staff. All four bedrooms, in use by residents, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There is one (1) bathroom designated for residents' use. The bathroom was properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 110.3 degrees Fahrenheit. No cleaning supplies or hazardous items were present in the bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Properly labeled medications were locked in one of the living area cabinets. Surrounding Grounds: LPA observed that outdoor area is cluttered. LPA observed old mattresses, wheelchairs, hospital beds, dining table, and electric saw. LPA also observed that both emergency exits were locked. There was furniture appropriate for outdoor, however, LPA was informed that residents don't go outside. (Continue 9099C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
	VISIT DATE: 07/29/2024

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
26
27
28
29
30
31
32

Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that Resident#3(R3) is missing the physician's report LIC 602. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. LPA observed that Staff#1(S1) and Staff#2(S2) files are missing LIC 501,508 and no first-aid certificate. Licensee and Administrator files are also incomplete.

Medications: Medication and Medication Records were reviewed for proper documentation. LPA was unable to conduct a medication audit. Medication Records were incomplete. Temperature: The facility maintains a comfortable temperature of 77 degrees Fahrenheit.

Exit interview conducted, citations issued, appeal rights given and a copy of this report delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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. LPA observed the fridge was unclean and the kitchen had clutter and an insect killer bottle. This is an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	The licensee immediately removed the insect killer and locked it in a cabinet and started cleaning the kitchen fridge.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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. LPA observed a cleaning solution under the kitchen sink in an unlocked cabinet. This poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	the licensee immediately removed all cleaning solutions under the kitchen sink

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. 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. The kitchen door screen is torn which allowed filies in the kitchen. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	The licensee will provide proof of purchase of new door screening by the POC date.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above. S1 and S2 are missing CPR certificates, LIC 501 and 508. The licensee and Administrator folders are incomplete. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	The licensee will email S1 and S2 missing forms and the entire employee file for the Administrator and the Licensee.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 4 of 7

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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. LPA observed breakfast area is cluttered. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	The Licensee will provide a picture of a clean kitchen and breakfast area.

Type B

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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. LPA observed spoiled food in the fridge. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	Licensee will provide a picture of clean fridge and proof of purchase of fruits and vegetables.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA was unable to complete medication audit due to incomplete forms. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	The Licensee will email LPA completed medications forms by the POC date.

Type B

Section Cited

CCR

87506(b)(13)

Resident Records

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. R4 have redness in the buttocks area and Licensee didn't notify CCL. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	Licensee will email SIR reporting the redness and skin condition of R4 by the POC date.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 07/30/2024 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA	FACILITY NUMBER: 197610165
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. R3 doesn't have LIC 602 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	Licensee will email LPA R3 LIC 602 by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 7 of 7