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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850375
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:48:06 PM


Document Has Been Signed on 09/17/2024 02:48 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:PACIFIC HEIGHTS RESIDENTIAL HOME LLCFACILITY NUMBER:
405850375
ADMINISTRATOR:CRADDUCK, CHERLYNFACILITY TYPE:
740
ADDRESS:781 LILAC DRIVETELEPHONE:
(805) 534-1589
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:5CENSUS: 5DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Cherlyn CradduckTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Rankin conducted an unannounced required annual visit to the facility above at 10:00 am. LPA met with Licensee/Administrator Cherlyn Cradduck and explained the purpose of today’s visit.

The following was inspected and noted during the visit:

Operational Requirements: The facility has current liability insurance expiring on 04/07/2025. The facility has an approved capacity of 5 with 4 Non-Ambulatory of which 1 may be bedridden in bedroom #2. The fire clearance was granted for 5 with 4 non-ambulatory and 1 bedridden. The facility has theft and loss policy as well as investigation procedures posted in front entry.

Physical Plant & Environmental Safety: The facility has 3 resident bedrooms and 2 resident bathrooms currently occupying 5 residents and employs 5 full time staff with back up staffing if needed. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide detector was tested and working properly, smoke detectors are hard wired. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. Residents are provided privacy and confidentiality. The pathways inside and outside are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents and locked under the kitchen sink and in the locked garage cupboards.
Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 09/17/2024 02:48 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: PACIFIC HEIGHTS RESIDENTIAL HOME LLC
FACILITY NUMBER: 405850375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that during the annual visit, the medication closet was found unlocked by LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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The administrator secured and locked all medications during visit.
The Licensee agreed to do the following:
1. Provide documentation of staff training regarding regulation 87465(h)(2) to CCL by 10/4/2024
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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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: PACIFIC HEIGHTS RESIDENTIAL HOME LLC
FACILITY NUMBER: 405850375
VISIT DATE: 09/17/2024
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The facility has sufficient space inside and outside for activities and visiting. The facility has a courtyard for resident use with an umbrella for shade. Telephone and internet service is provided for residents in care. The facility has a working washer and dryer with all needed supplies for operation. The facility has beds, mattresses, furniture and bedding in good repair. Fireplace is screened. Windows and screens are it good repair. Hygiene items such as soap and toilet paper are supplied by the facility for residents in care. Night-lights are maintained in the hallways for the safety of residents in care. There are no bodies of water on the premises. The facility does not allow firearms or ammunition to be kept at the facility.

Staffing: The facility staff 3 full-time staff and 2 staff with Administrators certificates, both certificates are valid and expires on 03/16/2025 and 05/2025.

Personnel Records & Training: The facility maintains confidential files for the Licensee, Administrator, and employees. All criminal records for clearance or exemption will be kept in those files. Staff 1st Aid/CPR and annual training was reviewed and found in compliance. Personnel records were reviewed, all required documentation was filed.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Pre-Admission appraisals are conducted on perspective residents before accepting them into care and kept on file. Resident files have signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables maintained in files. All resident files were in compliance.

Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the entry way of facility. The visitation policy and hours are posted at front entry.



Planned Activities: A comfortable space is provided inside and outside for activities and facility maintains an activities schedule and supplies for activities. The facility provides a furnished living area for relaxation and entertaining as well as a furnished courtyard with shade for resident use.
Continued on 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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: PACIFIC HEIGHTS RESIDENTIAL HOME LLC
FACILITY NUMBER: 405850375
VISIT DATE: 09/17/2024
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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. All food is covered, stored and marked appropriately. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter and insects. All equipment, supplies and dishes are kept clean and maintained in good repair.

Incidental Medical & Dental Services: Facility provides 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). Medications for all resident in care are centrally stored and locked in hallway medication closet. During visit LPA opened medication closet, which was unlocked, citation given.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. 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. Facility has emergency food and water supply. The facility has two evacuation locations and a place available for a backup generator if sheltering in place.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does have a resident currently using oxygen as needed and the facility does have a posted "No Smoking-Oxygen is in use", on the facility front door. The facility does not have any delayed egress. The facility has two self-latching, self-closing gates at each side of the building, all exiting doors are alarmed.

Exit interview conducted, citation and copy of appeal rights given, and copy of report printed for Licensee/Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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