197610501-6-19-2024-31-AS-RCOR-D6DLKJ-20240619084937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610501
Report Date: 06/18/2024
Date Signed: 06/19/2024 08:50:44 AM

Document Has Been Signed on 06/19/2024 08:50 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IVY PARK AT WEST HILLS		FACILITY NUMBER:	197610501
ADMINISTRATOR:	RYAN, MATTHEW		FACILITY TYPE:	740
ADDRESS:	9012 TOPANGA CANYON ROAD		TELEPHONE:	(818) 701-9550
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY:	90	CENSUS: 60	DATE:	06/18/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Matt Ryan		TIME COMPLETED:	03:30 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	On 06/18/24, 9:15 AM Licensing Program Analyst (LPA) Raymond Comer, conducted a scheduled pre-licensing inspection of the Facility. LPA met with Administrator, Matt Ryan. Facility is licensed as a two-story building with resident bedrooms, private bathrooms, and multiple public bathrooms. Fire clearance approved for (75) non-ambulatory, and an additional fifteen (15) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are fifty-two (52) Ambulatory residents, eight (8) Non-Ambulatory residents, none of which are bedridden, and seven (7) residents receiving hospice care services. LPA and the Administrator toured the physical plant with the Administrator and observed the following: Physical plant was inspected for cleanliness and condition. Facility’s main doors are the primary entry/exit access point, with three (3) emergency exits being located off the dining room area, and two stairwells. Emergency exit routes are clear of obstructions. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Facility is separated into Assisted Living and Memory Care floors. LPA observed the delayed egress system working properly. Room temperature is comfortable; wall thermostat displays a setting of 73°F., within the required range. The facility maintains required Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/30/2024. [LIC 809C-Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WEST HILLS	FACILITY NUMBER: 197610501
	VISIT DATE: 06/18/2024

NARRATIVE

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Fire Safety: Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are completed and documented, in house, on a monthly basis. Fire drill last conducted 5/30/2024. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced on 11/08/2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility.

Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. Resident food allergy info/reports are disseminated to Staff. No pesticides, nor poisons were observed near any food areas.

Medications: Medications were locked in rolling medication carts located on the second floor. Medications are properly labeled, stored and inaccessible to residents. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart and stocked with required supplies.

Laundry: At 11:25 AM, LPA observed laundry rooms located on the first and second floor. Residents in the assisted living wing of the facility have access to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies, and other toxins, are securely stored and inaccessible to residents. The Laundry room located in the memory care wing was observed as locked and inaccessible to residents.

Commons: LPA observed multiple common areas upstairs, and downstairs. Activity rooms, movie theaters, dining rooms, and library rooms observed to be clean and furnishings to be in good condition. No obstructions, nor tripping hazards observed.

[LIC 809C-Continued]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WEST HILLS	FACILITY NUMBER: 197610501
	VISIT DATE: 06/18/2024

NARRATIVE

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Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms were inspected and observed to maintain required furnishing and sufficient lighting, linens, blankets, closet space and dressers. All bedrooms were observed to be clean and clear of obstructions. Signaling system is present in all bedrooms to request staff assistance. LPA activated the signaling system in a randomly inspected bedroom and staff responded promptly. (Response time was within two (2) minutes)

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 115°F. Within the required range.

Outdoor: Courtyard areas observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights records were present, and Staff are associated to this facility. Staff records appear to be complete and current.

At 2:00 PM, LPA conducted the COMP III presentation with the Administrator and Assistant Administrator, and completed at 2:25 PM

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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