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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800609
Report Date: 04/15/2024
Date Signed: 04/15/2024 05:19:26 PM


Document Has Been Signed on 04/15/2024 05:19 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:SILVER HILLS RCFEFACILITY NUMBER:
425800609
ADMINISTRATOR:ALAN SEPULVEDAFACILITY TYPE:
740
ADDRESS:501 GARNET WAYTELEPHONE:
(805) 878-9056
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 5DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Alfonsito "Allan" SepulvedaTIME COMPLETED:
05:30 PM
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Licensing Program Analyst's (LPA's) De Leon and Rankin arrived at 10:20 am to conduct a 1 year annual visit to the facility above. LPA met Administrator Allan Sepulveda and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Infection Control: The facility Infection Control Plan on file. The facility has a sign in and out clipboard 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 disinfectants 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). Some trash cans and waste baskets have tight fitting covers, administrator agreed to replace those without lids.

Physical Plant & Environment Safety: The facility is a 6 bedroom and 4 ½ bathroom, with 1 bedroom and ½ bathroom dedicated to staff. The facility is occupying 5 residents and employs 5 staff of which one is the Administrator and one is a live in staff. The facility is clean, safe and sanitary, areas that need additional cleaning were noted to the administrator. LPA's were authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. Carbon Monoxide was tested and working properly. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The showers have non-skid mats with the exception of one that will be installed or replaced by the administrator. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with furniture and plenty of shade. The facility has telephone and internet service for resident use. The backyard has a locked shed to store extra furniture and items. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14


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: SILVER HILLS RCFE
FACILITY NUMBER: 425800609
VISIT DATE: 04/15/2024
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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. 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. 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, rodents, vermin and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts semi-annual disaster drills, administrator will be adding quarterly drills to his schedule. The fire extinguishers was charged and an inspector is coming out on 04/18/24 for annual. 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. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress. The facility does not currently have residents with oxygen. The facility does have 2 hospice residents in care. The facility has 3 residents currently on Home Health services. Home Health services records are kept on file. The administrator noted the facility gate will be updated with self-latching and self-closing equipment. The backyard is completely fenced. The facility has exiting door alarms, which were working on LPA's visit.

LPA conducted interviews with 2 staff and 1 resident.

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

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 13 of 14
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: SILVER HILLS RCFE
FACILITY NUMBER: 425800609
VISIT DATE: 04/15/2024
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Operational Requirements: The facility has a current plan of operation on file. The Facility is operating in compliance with the granted fire clearance based on the facility sketch. The facility has current liability insurance and expires on 03/20/2025. The facility is approved for a capacity of 6 non-Ambulatory and approved for hospice waiver of 4.

Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 4 staff files and one volunteer. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Back-up administrator will provide current copy of 1st Aid/CPR. Administrator file was reviewed for Continuing Education requirements and an Administrator Certificate expires on 7/13/24. All files were kept up to date with all requirements being met.

Personnel Records & Training: The facility keeps confidential files. LPA reviewed 4 staff training records for Annual Training Requirements of 20 plus hours. Administrator is in the process of completing Aprils training. Trainer met the requirements to train staff. Initial training was kept on file.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for 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. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The facility does not handle cash resources.

Incidental Medical & Dental: The facility has a medication cabinet in the family room that is kept locked. Facility provides or assist in providing transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cabinet for all prescription and PRN medications with Doctors orders. LPA reviewed all residents medications, No medications labels were altered, no expired medications, and medications were stored in original containers.


Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 14 of 14