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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690036
Report Date: 06/19/2024
Date Signed: 06/19/2024 03:28:37 PM

Document Has Been Signed on 06/19/2024 03:28 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR/
DIRECTOR:		JORDAN ARONOFFFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 6CENSUS: 6DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Cherokee MullerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. The LPA was greeted by House Lead Dayra Alamo, Administrator was contacted via telephone and arrived shortly after. At 12 p.m., LPA Kelly Dulek arrived at the facility.

Entrance interview conducted.

The LPA along with the Program Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a two-story house. The following was observed.

BEDROOMS/BATHROOMS: The LPA began the inspection with the downstairs bedrooms and bathrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated client rooms. There was a linen closet in the upstairs hallway with extra towels and linens. The client bathrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. LPA measured hot water temperature in all bathrooms which were within the required limit of 105-120 degrees Fahrenheit.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and cleaning supplies are stored inaccessible to clients. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Additional food supplies and emergency food supply are kept in the attached garage. Hot water temperature was measure at 114.6 degrees Fahrenheit.

Continued LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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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Document Has Been Signed on 06/19/2024 03:28 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/19/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the program director did not comply with the section cited above by having S1 working in the facility with a pending status in the Guardian system which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Program Director agreed to have S1 do his training off site. Program Director understands that S1 can not be in the facility until S1 gets Cleared in Guardian. S1 left the facility at the time annual inspection was over.
Type A
Section Cited
CCR
81069(f)(1)
Client Medical Assessments
(f) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/ infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 (one) out of 6 (six) clients did not have Negative TB Test on record which poses an immediate health and safety to persons in care.
POC Due Date: 06/20/2024
Plan of Correction
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Program Director agrees to provide a copy of chest XRay via email to LPA by the POC due 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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2024 03:28 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/19/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81069(a)
Client Medical Assessments
(a) Prior to admitting a client into care or within 72 hours of admission, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 5 (five) out of 6 (six) clients did not have Medical Assessments which poses an immediate health, safety to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Program Director agrees to provide a copy of their medical assessment via email to LPA for all five (5) by the POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024


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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 06/19/2024
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Continued from LIC 809

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested at 10:56 a.m. and operational at the time of the visit. The two (2) fire extinguishers observed were fully charged and were last serviced 10/18/2023. The LPA observed required postings throughout the common spaces. There is a laundry room attached to the garage and gym room, where the washer and dryer are held. Cleaning supplies, disinfectants and contraband items are kept locked in the laundry room.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. A pool was observed to be covered and inaccessible, exits are free of obstructions.

RECORDS: Clients’ records review began at 11:30 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. LPAs observed that five (5) out of six (6) clients didn’t have medical assessment on record. Client 1 (C1) had a positive TB test on file. Program Director stated that C1 had a chest Xray done last week however no test result has been received.

At 11:52 a.m., personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All personnel records are electronically updated in Lipu EMR system, no paper records on site. At 10:00 a.m., during physical plant tour with Program Director, LPA observed Staff 1 (S1) starting his shift. Administrator stated that today is S1 first day of work. LPAs checked the Guardian system for clearance, however on Guardian status for S1 is “In process”.

Continued from LIC 809C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 06/19/2024
NARRATIVE
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Continued from LIC 809C

MEDICATIONS: Medications review began at 2:00 p.m., medications are centrally stored and locked in the Medication Room. The LPA audited three (3) resident files. Medications for all clients were observed to be in compliance with Title 22.

The LPA obtained the following documents: LIC500 Personnel Report, Client Roster, Liability Insurance and Emergency and Disaster Plan.



The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil Penalties issued in the amount of $100. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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