405801720-3-11-2024-29-AS-EMIR-D39URS-20240311154914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801720
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:49:52 PM

Document Has Been Signed on 03/11/2024 03:49 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:	RESIDENCE, THE		FACILITY NUMBER:	405801720
ADMINISTRATOR:	MICHELLE MARCOS		FACILITY TYPE:	740
ADDRESS:	3220 CALLE MALVA		TELEPHONE:	(805) 596-0812
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 4	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Meynard Marcos, Administrator		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA Miller) arrived at 10:39 am to conduct a 1 year annual visit to the facility above. LPA met with Administrator Meynard Marcos and explained the purpose of the visit.A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectant spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: The fire extinguisher was last charged and inspected on March 8, 2024 and a second extinguisher was purchased on February 17, 2024. All trash cans and wastebaskets have tight fitting covers. The facility has 4 resident bedrooms, 2 bathrooms currently occupying 4 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and stored in the garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCE, THE	FACILITY NUMBER: 405801720
	VISIT DATE: 03/11/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on July 11, 2024. The facility is approved for a capacity of 6. The fire clearance is granted for 6 non-Ambulatory. Hospice is approved for 2.

Staffing: The facility currently employs 3 full time staff, 5 part time staff and 2 administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements. Administrator file was reviewed for and . Administrator Certificate expires April 10, 2025.

Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for various subjects/topics and hours for 2023.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 4 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored, and marked appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Continued 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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: RESIDENCE, THE	FACILITY NUMBER: 405801720
	VISIT DATE: 03/11/2024

NARRATIVE

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Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents medications, no labels were altered, no medications were expired and all medications were kept in their original containers.
Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill April 13, 2023. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 2 self latching gates on side of the home. The facility does not currently have hospice residents in care. The facility currently has residents receiving Home Health services. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report, citation, and appeal rights were issued and printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/11/2024 03:49 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: RESIDENCE, THE	FACILITY NUMBER: 405801720
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705

This requirement is not met as evidenced by: Fire and earthquake drills shall be conducted once every three months on each shift and shall include at a minimum all direct care staff.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Administrator will conduct a full emergceny drill with staff. Administrator agreed to submit supporitng documentation and a summary of scheduled emergency drills no later than March 25, 2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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