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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610417
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:00:23 PM


Document Has Been Signed on 09/06/2024 02:00 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ADVERTENCE SENIOR CAREFACILITY NUMBER:
197610417
ADMINISTRATOR:PO, GELENEFACILITY TYPE:
740
ADDRESS:6930 NESTLE AVE.TELEPHONE:
(747) 287-8543
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Valiant Po, CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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At 9:30 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Valiant Po. LPA was informed that the Administrator is on vacation and cannot be present. Staff called the Administrator and LPA explained the reason for the visit. The Administrator designated the staff to sign today's report and to continue the annual inspection with LPA. Physical tour was conducted with the staff and LPA observed the following:

This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden. Facility has five (05) bedrooms and three (03) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy.

Kitchen: At approximately, 9:40 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen cabinet. There is a fully charged fire extinguisher located by the kitchen area. The fire extinguisher was purchased on 11/17/2023.

Medications: At approximately, 9:50 AM LPA observed medications are centrally stored in the hallway cabinet. LPA observed that the keys are in the cabinet and the medications cabinet is unlocked. Additionally, LPA observed medications needing to be refrigerated in the main fridge of the facility and was unlocked and accessible to residents in care. Furthermore, review of R1's random medication revealed that the facility started Metformin HCL 500 MG Tablet (Diabetes Medication) on 07/13/2024. During today's visit LPA counted R1's medication and it was discovered that there was a discrepancy and nine (9) extra pills were in the bottle. LPA asked the staff for explaining and staff could not provide any answers. LPA also observed Centrally Stored Medication (LIC 622) records and observed that the staff put the medication start date as of 07/13/2024. Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ADVERTENCE SENIOR CARE
FACILITY NUMBER: 197610417
VISIT DATE: 09/06/2024
NARRATIVE
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Bedrooms: LPA observed total of five (5) bedrooms designated for resident’s use. LPA observed that bedroom # one (1) bedroom # two (2) are vacant at the time of the visit. In bedroom # five (5) LPA observed ointment in one of drawers of the resident accessible and unlocked. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed three (3) bathrooms of which one is designated for staff and visitors and two (2) for resident use only. Resident bathrooms appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. Hot water temperature measured at 105.8°F.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. LPA observed that the cabinet in the living room where cleaning supplies are being stored unlocked and accessible to residents in care. No other obstructions and or tripping hazards throughout the facility. The garage is being used as a staff room and LPA observed to be locked and inaccessible to residents in care. Laundry room is outside by the main entrance of the facility and LPA observed being locked with the laundry detergents.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:00 AM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside areas: At approximately, 10:10 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. In the back alley of the facility LPA observed sprays and paints unlocked and accessible to residents in care.


Between 10:30 AM to 11:30 AM, LPA reviewed records of four (4) residents and three (3) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies cited during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/06/2024 02:00 PM - 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ADVERTENCE SENIOR CARE
FACILITY NUMBER: 197610417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705(f)(2) Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above to make cleaning supplies, disinfectants, and ointment in residents rooms inaccessible to residents in care which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/09/2024
Plan of Correction
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The licensee shall provide training to all staff and submit a training log to LPA by the POC due date.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication.

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 by providing care and supervision to persons with dementia and having medications accessible to residents in care, which poses an immediate health and safety or pesonal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee agreed to schedule vendorized training for all staff by 09/09/2024, and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/06/2024 02:00 PM - 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ADVERTENCE SENIOR CARE
FACILITY NUMBER: 197610417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465- Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R1's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2024
Plan of Correction
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Licensee agreed to schedule vendorized training for all staff by 03/18/2024 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Licensee also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4