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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690045
Report Date: 07/01/2022
Date Signed: 07/01/2022 11:25:16 AM

Document Has Been Signed on 07/01/2022 11:25 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:BLAKE FORBESFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Blake ForbesTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:30 a.m. to conduct a legal/Non-compliance case management visit. The LPA met with staff and explained the reason for the visit.

The facility currently has a probationary license, which is effective from 9/1/2020 – 8/31/2023. At this time, the LPA observed that the facility had an outstanding balance of $1,362. The LPA shared the regulation regarding probationary fees, which states that a probationary monitoring fee equal to the annual fee, in addition to the annual fee, is assessed each probationary year. No late fees have been assessed at this time. The LPA informed staff that the Stipulation and Waiver; and Order must be posted in a conspicuous location.

The LPA toured the facility inside and outside with staff ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible. Appliances in the kitchen were clean; however, the dishwasher was inoperable. The facility has a sufficient supply of perishable and non-perishable food. At 10:09 a.m., the hot water in the kitchen registered at 107 degrees Fahrenheit.

BEDROOMS: Rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms was adequate. BATHROOMS: Bathrooms were stocked with supplies and paper towels. The showers and bathtubs are equipped with nonskid surfaces and/or mats. At 10:04 a.m., the hot water in the common restroom on the first floor measured at 131.2 degrees Fahrenheit.

LAUNDRY: The laundry area is in a separate room. Laundry detergent is stored inaccessible.

MEDICATIONS: Medications are kept locked and inaccessible in a hallway closet.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
VISIT DATE: 07/01/2022
NARRATIVE
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COMMON AREA: Upon entry, the LPA observed that the doorbell was inoperable. The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. There is a fireplace in the living room, front room/foyer, and small dining room but was observed without any tools. The facility maintained a comfortable temperature of 73 degrees. The fire extinguishers were fully charged.

THERAPY AND STAFF: The detached pool house is designed for therapeutic services and is inaccessible to clients unless supervised by staff. However, therapeutic services can take place in the Great Room, foyer, and outdoors on the first level, or in the movie theater on the second level. Files are stored electronically.

During today’s visit, the LPA compared the personnel report to the Department clearance list and identified that one employee (Staff #1) was working at this facility either without a clearance transfer or the clearance status was set to ‘Pending’. It was confirmed that S1 has worked at this location since 4/25/2022.

GARAGE AND GROUNDS: The garage is attached to the facility and converted to a staff room. It is also kept locked. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. The in-ground pool is appropriately fenced and locked. There were no imminent or immediate hazards noted.

INFECTION CONTROL: Upon entry into the facility, staff were not wearing the appropriate face coverings. The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The LPA observed signs throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, droplet precautions, and proper mask usage. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties assessed. Exit interview conducted. Copy of the report and appeal rights were issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/01/2022 11:25 AM - It Cannot Be Edited


Created By: Ashley Smith On 07/01/2022 at 10:54 AM
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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
81019(e)(1)

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81019(e)(1) Criminal Record Clearance. All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
This requirement is not met as evidenced by:
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The Licensee agrees to do the following:
1. Confirm that S1 is associated to the facility prior to allowing them to return to work.
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Based on record review, the Licensee did not comply with the section cited above, as there was one staff (S1) working whom were not associated to this facility, which poses an immediate health and safety risk to clients in care.
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Type A
07/05/2022
Section Cited
CCR81088(e)(1)

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81088(e)(1) Fixtures, Furniture, Equipment, and Supplies. 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 and not more than 120 degrees F
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The Licensee agrees to do the following:
1. Immediately adjust the water tank, inform CCL when this happens but no later than 7/5/2022
2. Keep at least a seven day water temperature log. Submit proof of completion no later than 7/15/2022
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as hot water measured at 131.2 degrees F, which poses an immediate health and safety risk to clients in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/01/2022 11:25 AM - It Cannot Be Edited


Created By: Ashley Smith On 07/01/2022 at 11:00 AM
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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2022
Section Cited
CCR
81072(a)(2)

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81072 Personal Rights(a)(2) (a) Each client shall have personal rights which include ... the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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The Licensee agrees to do the following:
1. Have an in-service training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 7/5/2022
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Based on observations, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights risk to residents in care.
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Type B
07/15/2022
Section Cited
CCR81087(a)

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81087(a) Building and Grounds. 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:
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The Licensee agrees to do the following:
1. Repair or replace listed items, and submit proof to the Department by 7/15/2022
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Based on observation, the licensee did not comply with the section cited above, as the doorbell and dishwasher were inoperable, which poses a potential health and safety risk to clients in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
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