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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690045
Report Date: 09/13/2023
Date Signed: 09/29/2023 11:26:54 AM

Document Has Been Signed on 09/29/2023 11:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
197690045
ADMINISTRATOR:SHELDON COHENFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 2DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Nesha Tandon, Administrator/Program DirectorTIME COMPLETED:
06:20 PM
NARRATIVE
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On 9/13/23 at 10:40 am, Licensing Program Analysts (LPAs) Darlene Chavez and Kelly Dulek conducted an unannounced Annual/Required visit. LPA met with Travis Brauker, Operations Supervisor, and Nesha Tandon, Program Director/Administrator, and explained the purpose of the visit.

LPA Chavez toured the facility with the Operations Supervisor and observed the following: Facility is maintained in conformity with state fire marshal regulations. Smoke detectors are hardwired with a sprinkler system. Carbon monoxide detectors are hardwired, tested, and functioning properly. Fire extinguishers were fully charged and last inspected on 6/1/23 and 10/26/22. The pool is surrounded by a fence with a locked gate. Fountains do not contain water. There are no fire arms or dangerous weapons in the facility. Hot water temperatures taken in client bathrooms and kitchen measured between 112.4 F and 127.2 F degrees. Deficiency cited. All toilets and hand washing facilities are maintained in a safe, sanitary, operating condition. The facility is clean, safe, and sanitary. The kitchen has two sinks and two dishwashers. One sink and one dishwasher are inoperable. Operations Supervisor states that the dishwasher has a leak under the dishwasher and sink and they have been inoperable since 9/7/23. Rust was observed on an exterior second story window. Rust area is approximately 2 feet x 2 feet. Deficiency cited. Each client is accorded safe, healthful, and comfortable accommodations, furnishings and equipment to meet his/her needs. There is a minimum 2-day supply of perishables and 7-day supply of nonperishable foods. Food is stored and prepared in a safe and healthful manner. Cleaning supplies were observed in an unlocked cabinet in the laundry room and garden fertilizer in the garden. Deficiency cited. Facility has adequate emergency supplies and first aid supplies. Facility temperature is 73 F degrees. Outdoor walkways are free from obstruction and the facility has outside areas for individuals to use. Centrally stored medication is kept secure in the locked office and inaccessible to clients. Medications are given as prescribed by doctors’ orders.

Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2023
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 09/29/2023 11:26 AM - It Cannot Be Edited


Created By: Darlene Chavez On 09/13/2023 at 05:25 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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81087(a)
Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in that one sink and one dishwasher in the kitchen are inoperable, and an area of rust on the second story window was observed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee has agreed to repair the dishwasher and sink leak and repair window rust. Licensee agrees to send LPA copies of the invoices of work completed by 9/20/23.
Type B
Section Cited
CCR
81087(l)
Buildings and Grounds
(l) The licensee shall ensure that items which could pose a danger if readily available to clients, including but not limited to disinfectants, cleaning solutions and poisons are stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in that cleaning supplies were observed in an unlocked cabinet in the laundry room and garden fertilizer in the garden which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee immediately placed supplies and fertilizer in locked cabinets. Licensee agrees to conduct training with staff on regulation and send trainin sign-in sheet to LPA by 9/20/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/29/2023 11:26 AM - It Cannot Be Edited


Created By: Darlene Chavez On 09/13/2023 at 05:25 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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on testing and interviews, the licensee did not comply with the section cited above in that hot water temperatures taken in client bathrooms and kitchen measured between 112.4 F and 127.2 F degrees which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee agrees to adjusting the water heater and take photos and send to LPA by 9/20/23.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in that quarterly drills are have not been conducted or documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee agrees to conduct an emergency disaster drill by the due date and send training sign-in sheets to LPA by 9/20/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
VISIT DATE: 09/13/2023
NARRATIVE
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Administrator states that quarterly drills are being conducted but was not able to provide documentation. Deficiency cited. LPA Dulek reviewed staff files for criminal record clearances and associations, Health screening with TB results, and current First Aid/CPR. One staff reviewed did have a criminal record clearance, but was not transferred to the facility prior to employment. Deficiency cited, civil penalty issued. LPA reviewed (2) client files for current TB tests, needs and services plans and signed admission agreements and personal rights. Files were in-compliance.

Exit interview conducted, deficiencies cited, civil penalty issued, and the report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/29/2023 11:26 AM - It Cannot Be Edited


Created By: Darlene Chavez On 09/13/2023 at 05:30 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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81019(e)(2)
Request a transfer of a criminal record clerance as specified in Section 81019(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in that one staff file reviewed did have a criminal record clearance, but was not transferred to the facility prior to employment on 4/17/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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Licensee will ensure staff are associated to facility prior to employment. Licensee agrees to write a Statement of Understanding of the regulation cited above and send to LPA by 9/14/23.
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:Kelly Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023


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